Arthur Freeman (Auth.), Arthur Freeman (Eds.) - Cognitive Therapy With Couples and Groups-Springer US (1983)

Cognitive Therapy with
Couples and Groups

Couples and Groups
Edited by
Arthur Freeman
Center for Cognitive Therapy
Philadelphia, Pennsylvania
Springer Science+ Business Media, LLC

Library of Congress Cataloging in Publication Data
Main entry under title:
Cognitive therapy with couples and groups.
Includes bibliographical references and index.
1. Cognitive therapy. 2. Marital psychotherapy. 3. Group psychotherapy. 1.
Freeman, Arthur M. [DNLM: 1. Behavior therapy. 2. Cognition. 3. Psychotherapy,
Group. WM 425 C6765]
RC489.C63C65 1983 616.891 15 83-13210
ISBN 978-1-4757-9738-1 ISBN 978-1-4757-9736-7 (eBook)
DOI 10.1007/978-1-4757-9736-7
©1983 Springer Science+Business Media New York

Originally published by Plenum Press, New York in 1983
Softcover reprint of the hardcover 1st edition 1983
AII rights reserved
No part of this book may be reproduced, stored in a retrieval system, or transmitted
in any form or by any means, electronic, mechanical, photocopying, microfilming,
recording, or otherwise, without written permission from the Publisher
To
Abe Freeman (1907-1951)
and to my sons,
Andrew, Russell, and Aaron,
with love
Contributors
}ANIS LIEFF ABRAHMS, Department of Psychology, Yale University, New

Haven, Connecticut
AARON T. BECK, Department of Psychiatry, School of Medicine, Univer-

sity of Pennsylvania, Philadelphia, Pennsylvania
RICHARD C. BEDROSIAN, Massachusetts Center for Cognitive Therapy,

Westborough, Massachusetts
DAVID D. BuRNS, Department of Psychiatry, School of Medicine, Uni-

versity of Pennsylvania, Philadelphia, Pennsylvania
ANNA RosE CHILDRESS, Department of Psychiatry, School of Medicine,

University of Pennsylvania, Philadelphia, Pennsylvania
NoRMAN EPSTEIN, Center for Cognitive Therapy, 133 South 36th Street,
MARK D. EvANS, Department of Psychology, University of Minnesota,

Minneapolis, Minnesota and Department of Psychiatry, St.
Paul-Ramsey Medical Center, St. Paul, Minnesota
ARTHUR FREEMAN, Center for Cognitive Therapy, 133 South 36th Street,
MEYER D. GLANTZ, National Institute on Drug Abuse, Division of Clini-

cal Research, 5600 Fishers Lane, Rockville, Maryland
VINCENT B. GREENWOOD, Center for Cognitive-Behavioral Therapy, 5225

Connecticut Avenue, N.W., Washington, D.C.
STEVEN D. HoLLON, Department of Psychology, University of Min-

nesota, Minneapolis, Minnesota and Department of Psychiatry, St.
Paul-Ramsey Medical Center, St. Paul, Minnesota
Vll
viii CONTRIBUTORS
SusAN }ASIN, California School of Professional Psychology, 3974 Sorren-

to Valley Boulevard, San Diego, California
WILLIAM McCouRT, Southwood Hospital, Norfolk, Massachusetts
STIRLING MooREY, The Maudsley Hospital, Denmark Hill, London SES,

England
MICHAEL W. O'HARA, Department of Psychology, University of Iowa,

Iowa City, Iowa
LAURA PRIMAKOFF, Center for Cognitive Therapy, Department of Psy-

chiatry, 133 South 36th Street, University of Pennsylvania, Phila-
delphia, Pennsylvania
LYNN P. REHM, Department of Psychology, University of Houston,

Houston, Texas
SusAN R. WALEN, Department of Psychology, Towson State University,

Towson, Maryland
RICHARD L. WESSLER, Department of Psychology, Pace University,

Pleasantville, New York
JANET L. WoLFE, Institute for Rational Living, 45 East 65th Street, New
York, New York
Foreword
It is with great pride and satisfaction that I welcome the publication of

Cognitive Therapy with Couples and Groups.
For several years, Arthur Freeman, Director of Clinical Services at
the Center for Cognitive Therapy, has been a leader in attempting to
extend a cognitive approach to new problems and new populations and
to expand the approaches for treating the depressed outpatients for
whom this approach was first developed. Dr. Freeman brought to the
Center the full range and depth of a diverse clinical background which
had and continues to broaden and enrich his work both as a therapist
and as a teacher. I believe he has applied these dimensions of his experi-
ence fully in developing and editing this volume.
The chapters in this book clearly reflect those clinical problems that
have attracted the keenest interest on the part of practicing cognitive
therapist, which are encountered so frequently in the course of treating
depression. The utilization of cognitive therapy with couples, families,
groups, and in training is a clear example of this process, an intriguing
topic in its own right. Conversely, coping with special clinical phe-
nomena such as loneliness is a familiar problem to therapists of de-
pressed patients. Laura Primakoff demonstrates her creativity and expe-
rience in her treatment of this subject. Similarly, the chapters on al-
coholism and agoraphobia are timely elaborations of the original cogni-
tive model for the individual treatment of depression. Vincent Green-
wood's chapter on the young adult chronic patient will, I believe, be
recognized as an innovative contribution to an area of particular clinical
difficulty.
Another notable aspect of this volume is the interweaving of ele-
ments from different cognitive therapy traditions. The chapter by
Michael O'Hara and Lynn Rehm extends Rehm's self-control model for
the treatment of depression to a group format. The lucid chapters by
Richard Wessler and Susan Walen and Janet Wolfe present cognitive
approaches from the framework of the rational-emotive therapists.
Other contributors, trained primarily at the Philadelphia Center or
by former staff of the Center, show the influence of cognitive therapy
developed at the University of Pennsylvania. Janice Abrahms and Nor-
ix
X FOREWORD
man Epstein offer two cognitively based views of theory and strategies of
working with distressed couples; Richard Bedrosian has integrated his
family therapy training and experience into an understanding of cogni-
tive therapy utilized within a family system. Steven Hollon, an early co-
worker of mine, offers a basic introduction to cognitive therapy of depres-
sion utilizing the group format. His co-author, Mark Evans, trained by
Hollon, represents the next generation of cognitive therapists.
Given his long experience in training and supervision, Dr. Freeman
closes his book appropriately with two chapters on cognitive approaches
to training. Not coincidentally, both are co-authored by David Burns
who has done much to enliven and diversify the time-honored pro-
cedures of individual supervision.
Cognitive Therapy with Couples and Groups should reward the clinician
with a stimulating view of a recent development in cognitive therapy-
its application to groups. I hope ths book will, at the same time, whet
the appetite for further exploration and experimentation in these areas.
AARON T. BECK
Department of Psychiatry
School of Medicine
University of Pennsylvania
Philadelphia, Pennsylvania
Preface
For virtually every model of individual psychotherapy that has been

developed a group model also has been developed, utilizing the same
basic theoretical format but applying it to dyads or larger groups. The
rationale for utilization of groups in therapy is based upon a broad range
of theory, philosophy, economics, and practicality. Given the efficacy of
the cognitive-behavioral model, it is not surprising that cognitive thera-
py has been applied and utilized in a broad range of group therapeutic
treatments. The purpose of this book is to offer clinicians theoretical,
conceptual, and practical models for the application of the cognitive
psychotherapy in a group format. The contributors are all experienced
clinicians who represent variations of the cognitive therapy model from
Beck's cognitive therapy to Ellis's rational-emotive therapy. What we all
have in common is the idea that behavior, emotion, and cognition are
related and that by modifying beliefs, attitudes, ideas, and images, we
can alter affect and behavior.
The present volume emerged as the natural consequence of a num-
ber of colleagues sharing with me ideas relative to their ongoing group
work. As we discussed group work, it became clear that cognitive thera-
py was being applied in a number of situations far beyond treating
depression. We all felt that it would be helpful to develop a vehicle to
share with other clinicians the ideas, conceptualizations, and treatment
strategies that had been developed. Over the last year and a half I have
had the opportunity to meet cognitive therapists at a number of interna-
tional conferences and meetings. They were applying cognition therapy
with groups and were interested in sharing their therapeutic experience
with others. The book therefore has grown markedly, both in size and
quality, from its original conception. What follows is not the last word
on group treatment. Even as the final manuscript was being typed, I had
become aware of clinicians working with groups whose ideas and prac-
tice would have fit well within the context of the present volume. The
work of these clinical researchers may be reported in a later volume.
It is traditional and customary for authors to thank all of those who
have contributed to the life and growth of a book. Being a traditionalist
by nature, I would like to thank all of the contributors without whom an
xi
xii PREFACE
edited volume could not exist. All are colleagues, some personal friends.
All have earned, by their work, my highest regard. Emmanual F. Ham-
mer, an early teacher and colleague, first introduced me to the theory
and practice of group psychotherapy. Although our theoretical paths
have diverged, Manny has taught me more about being a good therapist
than anyone else. Aaron T. Beck has been my major teacher in cognitive
therapy. Through my contacts and work with him, I have grown immea-
surably. His high standards and ideals have been an inspiration. Albert
Ellis, an early teacher and therapist, introduced me to cognitive therapy
as a problem-solving approach to life issues.
Special thanks go to Tina Inforzato who has taken my verbal ram-
blings and converted them to orderly typescript. Without her, this book
would not exist.
Dr. Karen M. Simon shares my life and my work. She is an enthusi-
astic supporter, gentle critic, and willing helper in moving this and other
projects from idea to completion. Finally, I want to thank my father, Abe
Freeman. Although he has been dead for many years, he introduced me
to books and encouraged me to read and to get the college education
that he never had. I had promised myself that if I ever wrote or edited a
book, I would dedicate it to his memory.
ARTHUR FREEMAN
Contents
Foreword Vll
AARON T. BECK
1. Cognitive Therapy: An Overview 1

ARTHUR FREEMAN
2. Cognitive Therapy for Depression

in a Group Format 11
STEVEN D. HoLLON AND MARK D. EvANS
3. Rational-Emotive Therapy in Groups 43

RICHARD L. WESSLER
4. Self-Control Group Therapy of Depression 67

MICHAEL w. O'HARA AND LYNN P. REHM
5. Cognitive Therapy in the Family System 95

RICHARD C. BEDROSIAN
6. Cognitive Therapy with Couples 107

NORMAN EPSTEIN
7. Cognitive-Behavioral Strategies to Induce and Enhance

a Collaborative Set in Distressed Couples 125
JANIS LIEFF ABRAHMS
X iii
xiv CONTENTS
8. Cognitive Therapy in Groups

with Alcoholics 157
MEYER D. GLANTZ AND WILLIAM McCouRT
9. Cognitive Therapy with the Young Adult

Chronic Patient 183
VINCENT B. GREENWOOD
10. Cognitive-Behavioral Treatment of Agoraphobia

in Groups 199
SUSAN ]ASIN
11. Sexual Enhancement Groups for Women 221

SusAN R. WALEN AND JANET L. WoLFE
12. One's Company; Two's a Crowd: Skills in Living Alone Groups 261
LAURA PRIMAKOFF
13. The Apprenticeship Model: Training in

Cognitive Therapy by Participation 303
STIRLING MooREY AND DAviD D. BuRNS
14. The Group Supervision Model in Cognitive

Therapy Training 323
ANNA RosE CHILDRESS AND DAviD D. BuRNS
Index 337
1
Cognitive Therapy
An Overview
ARTHUR fREEMAN
In the past several years, cognitive therapy has emerged as one of the
more powerful models of psychotherapy (Smith, 1982). There are two
interactive reasons for its emergence and popularity. First, cognitive
therapy has been demonstrated to be an efficacious model of treatment.
Second, a number of practitioners, impressed by the available outcome
studies, have learned more about cognitive therapy and have been im-
pressed by the results in their own practice.
Cognitive therapy generally has come to mean the work of Aaron T.
Beck (1976), but there are several cognitive therapies, including Albert
Ellis's (1962, 1973, 1977) rational-emotive therapy, Arnold Lazarus's
(1976, 1981) multimodal therapy, Donald Meichenbaum's (1977) cogni-
tive-behavior modification, and Maxie Maultsby's (1975) rational behav-
ior therapy. The issue of cognition as a central focus of psychotherapy
has also been proposed by psychoanalysts (Arieti, 1980; Bieber, 1981;
Crowley, in press; Frankl, in press). In discussing cognitive therapy in
this overview, I will offer a generic cognitive therapy under which all of
the models proposed in this text can be subsumed.
HISTORY
The historical roots of cognitive-behavior therapy are mixed. Kelley

and Dowd (1980) see cognitive therapy as growing out of the behavior
modification model, with the work of Bandura (1977a, 1977b) being an
important milestone. Beck and Ellis, however, credit their early training
ARTHUR FREEMAN • Center for Cognitive Therapy, 133 South 36th Street, University of
Pennsylvania, Philadelphia, Pennsylvania 19104.
2 ARTHUR FREEMAN
in Adlerian and Horneyan models as central to their formation of a

cognitive model of psychotherapy.
Rather than becoming embroiled in the argument of the origin of
cognitive-behavior therapy (a much more psychoanalytic focus), it may
be more appropriate to describe where we are, which offers a mix of the
behavioral and dynamic models. We borrow from our behavioral col-
leagues the scientific method, a focus on behavioral change, and a vari-
ety of behavioral techniques and strategies (i.e., graded task assign-
ments, scheduling, behavior rehearsal, and role playing). From our
dynamically-oriented colleagues we have taken the notion of the impor-
tance of understanding the internal dialogue and process. Although
avoiding the pitfalls of accepting the construct of the unconscious, the
cognitive therapist, nevertheless, works to make the unspoken spoken
and to help patients redirect their thinking, attitudes, and behavior.
DEFINITION OF COGNITIVE THERAPY
Cognitive therapy is a relatively short-term form of psychotherapy

which is active, directive, and in which the therapist and patient work
collaboratively. The goal of therapy is to help patients uncover their
dysfunctional and irrational thinking, reality test their thinking and be-
havior, and build more adaptive and functional techniques for respond-
ing both inter- and intrapersonally. Specifically, cognitive therapists
work directly with their patients proposing hypotheses, strategies for
testing them, and opinions. With the severely depressed individual, the
therapist's activity level must be high enough to supply the initial ener-
gy to complete the therapy work. He would not then rely on restatement
but rather on restructuring, on interaction rather than interpretation, on
direction rather than nondirection, and on collaboration rather than
confrontation.
Cognitive therapy is a coping model of psychotherapy as opposed
to a mastery model. The goal of cognitive therapy is not to "cure" but
rather to help the patient to develop better coping strategies to deal with
his or her life and work. By helping the patient uncover his or her
dysfunctional and irrational belief systems, the cognitive therapist sets
the model for patients to continue this process on their own.
THE MYTH OF SIMPLICITY
One of the myths about cognitive therapy is its total and absolute
simplicity. For many professionals initially seeing the cognitive model
CoGNITIVE THERAPY 3
demonstrated by major practitioners or by their students (many of the

authors represented in this volume), their first reaction is, "Oh, it's
easy. All I have to do is tell them what they are doing wrong," or "I just
have to get them to say more positive things." Although that may be
more reflective of the works of Norman Vincent Peale (1978), Dale Car-
negie (1982), and Fulton J. Sheen (1978), it is not what cognitive therapy
is. Cognitive therapy is not a collection of techniques, gimmicks, or
strategies to fool the patient. It is not a system whereby the therapist
tries to outargue, outreason, or outsmart the patient. Cognitive therapy
is not a superficial "Band-Aid" model of psychotherapy. It cannot be
learned in a single hour or a single week, but takes one to two years of
intensive training, which has been found demonstrated both at the In-
stitute for Rational Living in New York and at the Center for Cognitive
Therapy in Philadelphia. These institutions have shown that the most
effective training model is one including both didactic presentation and
demonstration of competence in supervised psychotherapy on an in-
house basis. Cognitive therapy is no simpler to learn or practice than
any other model of therapy. It would be astounding for someone to
observe in vivo or videotaped psychoanalytic sessions in which the psy-
choanalyst said virtually nothing and the patient free associated. The
budding therapist seeing this could say, "Yes, I could do that; I could sit
there and say 'ah-huh,'" or to observe classical Rogerian therapy where
the "ah-huh" is added to a restatement of the patient's statement. Cog-
nitive therapy is not as simple as ABC, that is, simply helping the pa-
tient to identify his or her irrational or dysfunctional belief systems. The
danger in utilizing the apparent ease of cognitive therapy as a reason for
practicing it can cause a number of difficulties. With the patient for
whom ABC is as simple as ABC then no problem exists at that moment.
However, the problems the majority of patients present are not that
simple, but rather require the therapist to develop a conceptualization of
the case within a cognitive frame and then decide which therapeutic
strategies best can be utilized to achieve the maximum therapeutic effect.
All humans appear to have a capacity to distort reality in a number
of significant ways. If the distortion is severe enough, the individual
may lose touch with reality and be labeled psychotic. However, the
neurotic distorts reality in particular significant and dysfunctional ways.
Beck (1976; Beck, Rush, Shaw, & Emery, 1979) and Burns (1980a,b) have
classified particular types of distortions that are seen more commonly.
These distortions are fueled by the basic life schemata or underlying
assumptions (similar to Ellis's rational and irrational beliefs). These irra-
tional belief systems or rules for living become a substrate, a wellspring
from which the basic cognitive distortions emerge. These schemata can
be established early in childhood. When an external event stimulates a
4 ARTHUR FREEMAN
particular schema, it generates specific distortions or more general styles

of distortion. Examples of these distortions include:
AU-or-nothing thinking. 1 This refers to the tendency to evaluate your
performance or personal qualities in extremist, black-and-white catego-
ries. For example, a prominent politician told me: "Because I lost the
race for governor, I'm a zero." A straight-A student who received a Bon
an exam concluded: "Now I'm a total failure." Ali-or-nothing thinking
clearly is illogical because things are not completely one way or the
other. For example, no one is either completely attractive or totally ugly.
Similarly, people are neither "absolutely brilliant" nor "hopelessly stu-
pid." All-or-nothing thinking forms the basis for perfectionism. It causes
you to fear any mistake or imperfection because you then will see your-
self as a complete zero and feel inferior, worthless, and depressed.
Overgeneralization. You arbitrarily conclude that a single negative
event will happen over and over again. For example, a shy young man
mustered up his courage to ask a girl for a date. When she declined he
thought: ''I'm never going to get a date. Girls are always turning me
down." A depressed salesman noticed bird dung on his car and
thought: "Just my luck! The birds are always crapping on my front win-
dow." When I questioned him about this he admitted that in his 20 years
of driving he could not remember another instance when he noticed bird
dung on his car!
Selective negative focus. You pick out the negative details in any situa-
tion and dwell on them exclusively, thus concluding that the whole
situation is negative. For example, a severely depressed college student
heard some premed students making fun of her roommate. She became
furious because of her thought: "That's what the human race is like-
cruel and insensitive!" She was overlooking the fact that in the previous
months few people, if any, had been cruel or insensitive to her. On
another occasion when she completed her first midterm exam she decid-
ed to commit suicide because she thought only about the 17 questions
she felt certain she had missed and concluded she could not succeed as a
college student. When she got the exam back there was a note attached
which read: "You got 83 out of 100 correct. This was by far the highest
grade of any student this year-A+."
Disqualifying the positive. This is to me one of the most amazing and
magical of all the thinking errors. When a depressed individual is con-
fronted with data that clearly contradicts his or her negative self-image
and pessimistic attitudes, he or she quickly and cleverly finds some way
to discount this. For example, a young woman hospitalized for chronic
1 This list and descriptions was developed by David Burns (1980).

CoGNITIVE THERAPY 5
intractable depression told me: "No one could possibly care about me
because I'm such an awful person." When she was discharged from the
hospital, many patients and staff members paid her a warm tribute and
expressed fondness for her. Her immediate reaction was: "They don't
count because they're psychiatric patients or staff. A real person outside
a hospital could never care about me." When I then asked her how she
reconciled this with the fact that she had numerous friends and family
who did seem to care about her she stated: "They don't count because
they don't know the real me." By disqualifying positive experiences in
this manner, the depressed individual can maintain negative beliefs that
are clearly unrealistic and inconsistent with everyday experiences.
Arbitrary inference. You jump to an arbitrary, negative conclusion
that is not justified by the facts or the situation. Two types of arbitrary
inference are mind reading and negative prediction.
1. Mind reading. You make the assumption that other people are
looking down on you and you feel so convinced about this that
you do not bother to check it out. You then may respond to this
imagined rejection by withdrawal or counterattack. These self-
defeating behavior patterns may act as self-fulfilling prophecies
and set up a negative interaction when none originally existed.
2. Negative prediction. You imagine that something bad is about to
happen and you take this prediction as a fact even though it may
be quite unrealistic. For example, during anxiety attacks a high
school librarian repeatedly told herself: 'Tm going to pass out or
go crazy." These predictions were highly unrealistic because she
had never passed out in her entire life and had no symptoms to
suggest impending insanity. During a therapy session, an acute-
ly depressed physician explained why he wanted to commit sui-
cide: "I realize I'll be depressed forever. As I look into the future,
I can see this suffering will go on and on, and I'm absolutely
convinced that all treatments will be doomed to failure." Thus,
his sense of hopelessness was caused by his negative prediction
about his prognosis. His recovery soon after initiating therapy
indicated just how off-base his negative prediction had been.
Magnification or minimization. I call this the "binocular trick" because
you are either blowing things up out of proportion or shrinking them.
For example, when you look at your mistakes or at the other fellow's
talents, you probably look through the end of the binoculars that makes
things seem bigger than they really are. In contrast, when you look at
your own strengths, or the other guys imperfections, you probably look
through the opposite end of the binoculars that makes things seem small
and distant. Because you magnify your imperfections and minimize
6 ARTHUR FREEMAN
your good points, you end up feeling inadequate and inferior to other
people.
Emotional reasoning. You take your emotions as evidence for the way
things really are. Your logic is: "I feel, therefore I am." Examples of
emotional reasoning include: "I feel guilty. Therefore I must be a bad
person." "I feel overwhelmed and hopeless. Therefore my problems
must be impossible to solve." "I feel inadequate. Therefore I must be a
worthless person." "I feel very nervous around elevators. Therefore
elevators must be very dangerous." Such reasoning is erroneous be-
cause your feelings simply reflect your thoughts and beliefs.
Should statements. You try to motivate yourself to increased activity
by saying, "I should do this" or "I must do that." These statements cause
you to feel guilty, pressured, and resentful. Paradoxically, you end up
feeling apathetic and unmotivated. Albert Ellis calls this
"musturbation."
When you direct "should" statements toward others, you probably
feel frustrated, angry, or indignant. When I was five minutes late for a
session, an irate patient had the thought: "He shouldn't be so self-cen-
tered and thoughtless. He ought to be more prompt."
Labeling and mislabeling. Personal labeling involves creating a nega-
tive identity for yourself that is based on your errors and imperfections
as if these revealed your true self. Labeling is an extreme form of over-
generalization. The philosophy behind this tendency is: "The measure
of a man is the mistakes he makes." There is a good chance you are
involved in self-labeling whenever you describe yourself with sentences
beginning with "I am. "For example, when you goof up in some way,
you might say, "I'm a loser" instead of "I lost out on this," or you might
think ''I'm a failure" instead of "I made a mistake."
Mislabeling involves describing an event with words that are inac-
curate and heavily loaded emotionally. For example, a physician on a
diet ate a dish of ice cream and thought: "How disgusting and repulsive of
me. I'm a pig. "These thoughts made him so upset that he ate the whole
quart of ice cream.
Personalization. You relate a negative event to yourself when there is
no basis for doing so. You arbitrarily conclude that the negative event is
your fault, even when you are not responsible for the event and did not
cause it. For example, when a patient failed to do a self-help assignment
that a psychiatrist suggested, the doctor thought: "I must be a lousy
therapist, or else he would have done what I recommended. "Similarly,
when a mother saw her child's report card, there was a note that her
child was not working effectively. She immediately concluded, "I must
be a bad mother. This shows how I'm goofing up."
Although all of the preceding distortions are negative and can lead
COGNITIVE THERAPY 7
to dysfunctional behavior, it should be noted that at some point each of

them most likely would have had a functional use. The ability to monitor
and assess our behavior and experience is an important part of this
function. When this is taken to an extreme, however, it becomes dys-
functional. It is important for individuals to learn to monitor nonverbal
cues, but when they monitor them and make inferences about behavior
(arbitrary inference) it may be dysfunctional. Striving for success is an
important part of the American ideal but, taken to the extreme of all or
nothing, it becomes a perfectionism that leads to dysfunction.
Another possible distortion that lends itself to improved productivi-
ty or greater risk taking may be termed positive distortion. Here the indi-
vidual acts as a personal cheerleader, telling him or herself that he or she
can do it and that the attempt would be worthwhile even though some
objective measure might indicate that he or she would not have the
necessary skills for successfully attempting or completing a particular
task. However, the experience gained in the attempt may serve to make
the individual better able to be successful later.
UNDERLYING ASSUMPTIONS AND IRRATIONAL BELIEFS
The source of the distortions are the irrational belief systems. They
are of various strengths and include social learning-please and thank
you; religious learning-the shalt and shalt nots; and internalization of legal
codes-walk/do not walk. The individual's degree of belief in these un-
derlying assumptions or rules of living will determine his or her strength
as a wellspring of distortions.
An example of this connection can be seen in the following recon-
struction. A child of elementary school age comes home from school
with a 98 on a math test. The parents either overtly or covertly inquire
about the other two points with statements such as, "I thought you
knew that work?" or "What happened to the other two points?" When
the child came home with a perfect exam paper, the child was greeted
with smiles, hugs, and kisses (a 98 only warranted a pat on the back and
better luck next time). A basic rule of life developed in this way would
be: To be accepted and/or loved, I must/should/ought to be perfect.
With this as a basic underlying belief, the individual dichotomizes expe-
riences as success (100%) or failure (99. 9% or below).
TREATMENT
In terms of treatment, the first issue looked at would be the distor-

tion, using the style, type, and content of the distortion to point to the
underlying assumptions. A patient often will terminate therapy having
8 ARTHUR fREEMAN
learned to cope successfully with his or her distortions but leaving the
underlying assumptions untouched. The more elegant solution, howev-
er, would be to have the individual cope not only with the distortions
but with the assumptions.
SPECIFICITY
The cognitive therapist makes up problem lists and specifies the

problems to be worked on. Patients coming into treatment to work on
depression or communication or, the most ambiguous of all, "to get
their head together," do not present symptoms that can be worked on or
problems that can be ameliorated. The cognitive therapist first needs to
assess the problems and then prioritize them. Lazarus (1981) spells out
the need for specificity in his BASIC 10 model where the clinician evalu-
ates problems in terms of Behavior, Affect, Sensation, Imagery, Cogni-
tion, Interpersonal relationships, and Drugs/Diet (physiologicalissues).
COGNITIVE AND BEHAVIORAL STRATEGIES
A number of cognitive strategies are utilized to help patients test the

reality of their cognitions:
1. Questioning the evidence
2. Reattribution
3. Fantasizing consequences
4. Understanding idiosyncratic meaning
5. Developing options and alternatives
6. Decatastrophizing
Behavioral strategies include:
1. Graded task assignments
2. Activity scheduling for mastery and pleasure
3. In vivo work
4. Collecting evidence
HoMEWORK
An important part of cognitive therapy is the idea that therapy does

not happen an hour or two hours a week but needs to be a process that
is constantly lived. The cognitive therapy patient is not being therapized
COGNITIVE THERAPY 9
so much as collaborating with the therapist. An important part of the

collaboration is doing self-help work at home. Our clinical experience
has indicated that the patients who do more self-help work move along
more quickly in therapy and are able to meet their stated therapy goals
more quickly.
The contributors to this volume have taken the basic cognitive
model and extended it to new populations and problems utilizing the
group context. The reader is encouraged to be familiar with the basic
model before attempting to utilize the application described here.
REFERENCES
Arieti, S. Cognition in psychoanalysis. Journal of the American Academy of Psychoanalysis.

1980, 8, 3-23.
Bandura, A. Self-efficacy: Towards a unifying theory of behavior change. Psychological
Review, 1977, 84, 191-215.(a)
Bandura, A. Social/earning theory. Englewood Cliffs, N.J.: Prentice-Hall, 1977.(b)
Beck, A. T. Cognitive therapy and the emotional disorders. New York:International Universities
Press, 1976.
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Guilford, 1979.
Bieber, I. Cognitive psychoanalysis. New York: Aronson, 1981.
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2
Cognitive Therapy for
Depression in a Group Format
STEVEN D. HoLLON AND MARK D. EvANS
INTRODUCTION
Can depressed patients be treated with cognitive therapy in a group

format? We think that they can. Cognitive therapy, the systematic at-
tempt to identify and alter dysfunctional, depressogenic cognitions, ap-
pears to be a powerful intervention for depressed clients. A group treat-
ment format allows the clinician to treat more peoyle in the same
amount of therapy time. In addition, a group format may offer certain
advantages not available in an individual treatment context.
In this chapter, we focus on the steps involved in practicing group
cognitive therapy with depressed clients. Our primary interest is in
actual therapy procedures. What steps need to be taken and what ma-
neuvers are likely to prove effective? In an effort to highlight clinical
mcJ.terial, we have relied heavily on vignettes drawn from actual group
clinical sessions. The reader interested in a more theoretical discussion
should consult Hollon and Shaw (1979).
THE EFFICACY OF GROUP APPROACHES
Depressed and suicidal clients traditionally have been considered

poor candidates for group therapy (Christie, 1970). Concerns have in-
STEVEN D. HoLLON AND MARK D. EvANS • Department of Psychology, University of

Minnesota, Minneapolis, Minnesota 55455 and Department of Psychiatry, St.
Paul-Ramsey Medical Center, St. Paul, Minnesota 55101. Preparation of this chapter was
supported in part by a grant from the National Institute of Mental Health (R01-MH33209)
to the Department of Psychology, University of Minnesota, and the St. Paul-Ramsey
Medical Education and Research Foundation (No. 6287).
11
12 STEVEN D. HOLLON AND MARK D. EVANS
volved both fears for the depressed patient and fears for the welfare of
the group. With regard to the patient's welfare, it often is stated that the
particular needs of such patients are so intense, but their performance
capacities so impaired, that they are unlikely to benefit from group
process. With regard to the group's welfare, the pervasive pessimism,
self-absorption, and rejection of others' suggestions are seen as impedi-
ments to the developments of the group process.
Yalom (1970) has suggested that these considerations may be less of
a constraint on including depressed patients in groups than on includ-
ing depressed patients in groups with other types of patients. Such
mixed groups typically have been referred to as heterogeneous groups.
We tend to concur with Yalom in not wanting to mix depressed clients
with other types of patients in a traditional group format. The bulk of
our experience with such patients has involved groups homogeneous with
regard to diagnostic composition. However, we do not want to rule out
the possibility that it is the type of therapy, not the type of group, that is
critical.
A brief review of the therapy outcome literature with respect to
depressed patients should suffice to document this point. Efforts to treat
homogeneously depressed patients with traditional psychotherapy gen-
erally have proven unsatisfying, regardless of whether that treatment
was provided individually (Daneman, 1961; Friedman, 1975; Klerman,
DiMascio, Weissman, Prusoff, & Paykel, 1974) or in groups (Covi, Lip-
man, Derogatis, Smith, & Pattison, 1974). Cognitive therapy, on the
other hand, has proven consistently effective in treating such patients,
whether provided in an individual format (e.g., Hollon, Bedrosian, &
Beck, 1979; Rush, Beck, Kovacs, & Hollon, 1977; Taylor & Marshall,
1977) or a group format (e.g., Gioe, 1975; Morris, 1975; Rush & Watkins,
1981; Shaw, 1977; Shaw & Hollon, 1978). The interested reader would do
well to consult these articles or recent major reviews (e.g., Blaney, 1981;
Craighead, 1981; Hollon, 1981; Hollon & Beck, 1979; Rehm & Kornblith,
1979; Shaw & Beck, 1977; Weissman, 1979) for more in-depth discus-
sions of this literature. None of these studies has yet contrasted diag-
nostically homogeneous with diagnostically heterogeneous groups. Al-
though we can be reasonably comfortable in suggesting that group
cognitive therapy appears viable with homogeneously depressed pa-
tients, it would be premature, at this time, to rule out diagnostically
heterogeneous groups, so long as the basic approach were cognitive.
The basic failure of traditional approaches to assist depressed clients in
heterogeneous groups may be attributable more to the nonviability of
the process-orientation of such groups for depressed clients than to the
heterogeneous composition.
COGNITIVE THERAPY FOR DEPRESSION IN GROUPS 13
The available evidence favors a structured, time-limited, problem-

focused approach such as cognitive therapy over other alternative group
approaches for working with depressed clients. Cognitive therapy, de-
spite its name, is not limited in focus solely to cognitive phenomena.
Rather, a broadly based range of cognitive, behavioral, and affective
change strategies are brought to bear in an integrated fashion on the
beliefs and actions of the depressed individuals (see Beck, Rush, Shaw,
& Emery, 1979; Emery, Hollon, & Bedrosian, 1981; Hollon & Beck, 1979;
or Shaw & Beck, 1977 for extended discussions of therapeutic rationale
and procedures). How can these procedures best be adapted for group
work with depressed clients? In the sections that follow, we focus on
those steps we believe necessary actually to implement cognitive thera-
py with depressed clients.
STRUCTURAL CONSIDERATIONS
As in individual cognitive therapy, the fundamental goals of group

cognitive therapy include an identification and modification of de-
pressed patients' maladaptive belief systems and dysfunctional forms of
information processing. Basic techniques include behavioral assign-
ments; systematic self-monitoring of activities, affects, and cognitions;
and training in strategies designed to identify and change distorted
cognitive systems. Much of the work goes on between sessions, with the
client making extensive use of a variety of structured homework assign-
ments. These include activity schedules, records of cognitions, and dys-
functional thought records as bases for efforts to change these cogni-
tions. Patients and therapists frequently collaborate with one another in
the design of "experiments"to test views held by those clients.
Other group members frequently can play a major role in identify-
ing, examining, and testing one another's belief systems. This capacity
to assume a therapeutic stance toward one another has, we believe,
several useful functions. Taking such a role (1) provides practice in
identifying and critically examining beliefs,{2) minimizes "distance" be-
tween "helper" and "helpee," (3) increases the probability that some-
one in the room will think of something, and (4) demonstrates to pa-
tients that they can, indeed, think quite rationally.
As in individual cognitive therapy, group sessions are structured,
problem-oriented, and focused. Therapists typically take an active role
in terms of questioning, challenging, exploring, and instructing. Incor-
porating such procedures in a group format can present a host of special
problems in terms both of the focus of the sessions and in a number of
14 STEVEN D. HoLLON AND MARK D. EvANS
practical problems that may arise in a group context. In the following

section, we illustrate several of these issues.
Problem-Oriented versus Process-Oriented Groups

Cognitive therapy is, in essence, a problem-oriented approach to
treatment. Process is dictated by the therapeutic strategy; early sessions
generally focus on behavior change and training in self-monitoring, with
the therapist carrying the bulk of the responsibility for presenting and
demonstrating the use of cognitive restructuring procedures. In later
sessions, the clients take an increasingly greater role in the cognitive
testing process. The key point is that therapeutic change is not seen as
being the result of insights growing out of group interaction. Rather, it is
considered the result of the application of specific change strategies
taught by the therapist but utilized by the patients. The goal of the
group is not to discover a strategy for change, but to teach a methodol-
ogy for change. Nonetheless, psychological problems related to the
group process occasionally may arise. Often, they can serve as "grist for
the therapeutic mill," rather than simply being nuisances or distrac-
tions. The vignette that follows illustrates this point. One group mem-
ber, Erik, had joined a group about three weeks after it had started but,
despite being quite depressed, had shown rapid change. A second
member, the other male, Craig, who had started therapy several weeks
earlier and initially had shown good progress, became increasingly crit-
ical of himself and appeared to be losing ground therapeutically. The
following vignette is adapted from audio tapes of the exchange that
followed:
THERAPIST 1: Craig, how about for you? How have things been going?
CRAIG: All right I guess ... not real good, but all right.
THERAPIST 1: Anything for the agenda?
CRAIG: Not really ... well, I just wonder how much I'm getting out of the
group ... I wonder if I should really continue.
THERAPIST 1: What leads you to wonder about that?
CRAIG: Well, I just don't seem to be doing too well lately.
THERAPIST 2: You've not been as active in group and today's the first session in
weeks that you haven't done any "triple-columns." Have your Beck scores
(Beck Depression Inventory: Beck, Ward, Mendelson, Mock, & Erbaugh,
1961) changed at all?
CRAIG: Well, I've been feeling worse ... (looks through folder) . .. Yeah, I'm at a
27 today, I was a 25last week ... I was down in the 10-15 range a couple of
weeks back.
THERAPIST 2: Well let's put that on our agenda and come back to it. It sounds like
something important is going on.
Later in the session
THERAPIST 1: Well, Craig, maybe we had better come back to your concerns
about staying in group. What do you think might be going on?
CRAIG: I don't know ... I just don't feel as comfortable, I don't feel like I can
keep up, or something.
THERAPIST 2: Don't feel you can keep up? What do you mean by that?
CRAIG: Well, like maybe I don't understand, like maybe I'm not smart enough.
THERAPIST 2: If you can't keep up, and if that's because you're not smart enough,
where does that leave you?
CRAIG: Well, it doesn't make a whole lot of sense for me to continue in group.
THERAPIST 2: I see, I think. If you believe that you aren't smart enough to follow
what's going, then you can't keep up well, and there's little reason for you to
continue. Is that what you've been thinking?
CRAIG: Yeah, that's a lot of it.
THERAPIST 2: Want to test those beliefs?
CRAIG: Yeah, I guess so. Let's see. First I ask myself what my evidence is ... I
don't know, I guess my evidence is that I haven't been keeping up.
THERAPIST 1: Specifically?
CRAIG: Well, I don't seem to be following things as well in the sessions, and I
haven't been doing much between sessions.
THERAPIST 1: You seem to think that's because you are too stupid. Any other
possible explanations?
CRAIG: Like what?
MARY: Like maybe you're sitting there so preoccupied with being stupid that
you haven't been listening?
CRAIG: (Laughs) Yeah, maybe, I have been doing a lot of that ... But seriously,
look at Erik. He started so much later, and look at how fast he's been learning
this.
THERAPIST 1: Oh, so you've been comparing yourself to Erik. Is that what's
started this all off?
CRAIG: Well, a lot of it. He just seems so much smarter than me.
ERIK: (Laughs) I don't feel that way; actually, I've been feeling kind of guilty
about taking up so much of the time; I've been feeling like I could never catch
up with the rest of you all.
THERAPIST 2: Let's take a very careful look at that notion of yours Craig about
being "stupid" and not being good enough. Let's go back again and look at
the evidence for and against that belief.
Dealing with such ongoing cognitions arising in group can provide a

powerful learning model. In all cases, the process is secondary to the
procedure, and is used as a means to help teach cognitive therapy tech-
niques, not to supplant them.
Open versus Closed Groups

In the vignette above, a new member had been added to an existing
group. Such a group is said to be an open group. Groups in which all
clients start at a given time are considered closed. We have run cognitive
therapy groups of both types and find that each has its advantages, each
its liabilities. Open groups are somewhat more flexible and often fit
ongoing clinical practices more adequately. When advanced group
members are encouraged to take a tutorial role with newer members, the
introduction of new members can provide an opportunity to teach what
has been learned. (We are struck by how closely our practice has fol-
lowed the old medical school dictum, "Watch one, do one, teach one.")
Closed groups, meanwhile, permit moving numerous individuals
along at a similar pace. This may prove to be a more economical pro-
cedure with regard to the way group time is spent. At this time, neither
practice can be said to be clearly superior to the other.
Role of Co-therapists
We prefer the use of co-therapists or multiple therapists. Working
with depressed clients can be particularly demanding. Such patients
often are doing the worst when they are saying the least. Use of co-
therapist allows at least one therapist continually to monitor group num-
bers not actively involved at any given moment.Similarly, the large
amount of written material generated by patients between sessions
often is best reviewed by one therapist as the other gets the session
started. Nothing is so likely to undermine patients' activity between
sessions as lack of therapeutic attention to their products during the
subsequent session. Use of co-therapist, with appropriate role division
(and, perhaps, role switching) appears to maximize therapeutic impact.
Group Composition
We already have discussed at some length the issue of hetero-
geneous versus homogeneous group composition. As noted, it is not
clear that heterogeneous groups will not prove feasible, but most of the
work, to date, has been done with homogeneous groups.
Few guidelines exist with regard to type of depression. Our pre-
vious work suggests that, if anything, greater endogenicity and lessor

chronicity are better prediction of outcome (Rush, Hollon, Beck, &
Kovacs, 1978). It is important to keepin mind, however, that efforts at
selection based on such evidence tend to make therapists feel better than
patients. From the potential patient's point of view, the question of
interest is not "Will I do as well in this therapy as someone who is more
endogenously or less chronically depressed?" Rather, it is "Given that I
am not very endogenous and my depression has been long-lasting, will I
do better in this type of treatment than in some other approach?" Stated
in this fashion, it becomes clear that selection really should be keyed to
differential outcome studies. Although we are beginning to get a sense
for patients more likely to improve than others, for example, endoge-
nously depressed middle-aged maleswith acute onset, we suspect these
are general prognostic factors. As such, they are not likely to be helpful
in selecting group patients.
Frequency and Duration of Session

There appear to be no firm guidelines as to the frequency and dura-
tion of sessions. Shaw and Hollon (1978) utilized two-hour sessions held
once a week for 12 weeks; Rush & Watkins (1981) held shorter meetings
twice weekly. Future studies might well address this issue.
For the present, our experience suggests that sessions lasting from
one and one-half to two hours provide an optimal time frame for com-
prehensiveness without fatigue. Weekly contacts appear to represent
minimum frequency.
CONDUCTING GROUP C/B
Preparatory Interviews
Upon entrance into a therapy group, a depressed patient may feel
particularly threatened. This apprehension could be reflected in
thoughts such as, "I couldn't possibly talk about my problems in front of
all those people," "I get uncomfortable in groups," "I must be an unin-
teresting patient," or "I must be too sick (or not depressed enough) to
benefit from individual therapy." Preparatory interviews scheduled for
discussing these or related concerns are helpful.
Conducting Sessions
Assessing Depression
We prefer to begin cognitive group therapy (see Table 1) with one or
more structured assessments of target problems. The Beck Depression
Inventory (BDI; Beck, Ward, Mendelson, Mock, & Erbaugh, 1961) pro-
vides a brief, well validated self-report measure of syndrome depres-
sion. The initial interview, the first group therapy session, and all subse-
quent group sessions routinely begin with an administration of the BDl.
Patients who have completed the BDI several times may be given a
supply to keep at home and may fill out the scale either just before
coming or while waiting for the group session to begin.
Such attention to the BDI permits a close monitoring of depression
levels, signals any important shifts in discrete symptomatology (such as
suicidal ruminations), and clearly keeps the focus on the production of
change within the time-limited contract. Although depression generally
is the major phenomenon of interest, we have at times monitored other
relevant processes, such as anxiety, on a regular basis. An additional
measure recently developed by Hollon and Kendall (1980), the Automat-
ic Thoughts Questionnaire provides a useful assessment of negative
beliefs, cognitions, and self-statements often experienced by depressed
persons.
Setting Agendas
At the beginning of each session, it generally is desirable to set a
flexible agenda that will allow patients and therapist(s) to target specific
areas for discussion. It frequently is useful to poll each participant for
suggestions so that everyone may begin the group session with some
kind of active participation. This enables group participants to comment
on major events or changes in sympotomatology over the preceding
week. It also decreases the chance that a participant will spring a "hot"
topic on the group in the midst of a session, either disrupting an on-
going discussion or coming so late in the session that there is not ade-
quate time to discuss it. The therapist(s) adds topics that he or she wants
to be sure are covered (e.g., homework or didactic material) and takes
the lead in prioritizing agenda items so that the most important items
are sure to be covered. Generally, itis preferable to specify a topic, then
continue to complete the construction of the agenda and return to that
topic later, rather than risk dwelling too long on any given subject at the
beginning of the session.
TABLE 1
Schedule for Group Cognitive Therapya
Week Session objectives and methods
0 Diagnostic and/or preparatory session 1. Assess appropriateness for group

2. Assess and discuss expectations
3. Distribute Coping with Ocpressio11
Initial session 1. Measure depression (give BDI)
2. Introduce new members
3. Set agenda
4. Establish ground rules
5. Discuss expectations and review
treatment goals
6. Elicit initial statements of indi-
vidual problems
7. Introduce cognitive theory and
technique
9. Focus on training self-monitoring
skills and/or behavioral experi-
ments
10. Homework assignments
11. Assess reactions to session
2-10 Subsequent sessions 1. Measure depression (give BDI)
2. Set agenda
3. Review status since last session
4. Discuss reactions to previous ses-
sions
5. Review homework from last ses-
sion
6. Introduce new topics and relate
material to basic cognitive theory
7. Homework assignments
8. Assess reaction to session
9. Summarize session
11-12 Termination sessions 1. Measure depression (give BDI)
2. Set agenda
3. Review status since last session
4. Discuss progress to date
5. Discuss expectations regarding ter-
mination
6. Assess reactions to session(s)
7. Summarize sessions
"Adapted from Hollon and Shaw (1979).
This approach provides an explicit, formal structure within which

the group can function at maximal efficiency. When a therapist is work-
ing with depressed patients, it is important that he or she has such a
structure planned in advance and available at all times. Such a strong
organizational aid also serves as a precaution against the deadly effects

of depressive inertia and pessimism that so readily appear during un-
focused moments. Far from inhibiting spontaneity during the group
session, an predetermined agenda appears to facilitate spontaneity and
involvement on the part of the patients. It seems likely that the apparent
poor prognosis for depressed patients in less highly structured groups
or in process-oriented group settings may be attributed to the failure of
such unstructured groups to offset adequately the operation of negative
cognitive sets. These negative sets seem to dominate in situations where
the lack of structure permits ambiguity, thereby creating a meaning
vacuum that are filled by the patients' depressive interpretations.
When a new group is starting and before individual patients' con-
cerns are taken up, it is useful to indicate clearly those areas that must be
discussed at the first session (e.g., the general structure for sessions,
group ground rules, individual goals and expectations, and a general
discussion of cognitive therapy). If a new member is being added to an
existing group, the therapist typically will use this time to make intro-
ductions and to indicate that some time will be set aside for exploring
the new member's goals, problems, and current situation.
Establishing Ground Rules

In the initial session, it is useful to discuss basic ground rules,
eliciting agreement from all participants. Confidentiality presents spe-
cial problems in a group setting. We typically approach the issue di-
rectly, requesting that each patient agrees to respect the other patients'
rights to privacy. A general guideline is that all patients are free to
discuss their own specific goals, progress, and the procedures they are
learning with whomever they choose, but that no other member is ever
identified nor their problem talked about.
The second major ground rule that is useful is the notion of "going
around." This means that the group agrees to structure its time in such a
way that each member might have an opportunity to bring up one or
more of his or her concerns for discussion and that the group will stay
with that topic long enough to reach some kind of resolution. Input is
actively sought from each patient who has not already volunteered com-
ments. This procedure prevents the flow of the discussion from becom-
ing too diffused, while also ensuring that no patient gets neglected.
Early in any given session and during the first several sessions, it usu-
ally is advisable for the therapist to be somewhat more formal in solicit-
ing comments from each member in turn, just as was done in setting the
agenda.
Depressed clients typically start therapy identifying with one an-

other's negative perceptions. Initially, comments from other group
members often take the form of agreement with the pessimistic view,
followed by recounting of idiosyncratic experiences or inferences from
the commenting member about his or her own situation. These com-
ments have the effect of diverting attention from the initial problem and
the initial speaker. It is unlikely that this process reflects anything more
than a spontaneous desire to empathize and/ or identify with the first
speaker. The therapist generally can redirect the discussion to the initial
topic and the initial speaker, then proceed to examine and work through
the initial problem raised.
Assessing Expectations and Eliciting Reactions to Previous Sessions

Early in the initial session, the therapist might find it useful to ask
each patient what he or she expects therapy to be like and what his or
her personal goals and expectations are for participation in the group.
The answers to these questions may provide useful indications of unre-
alistic expectations (generally negative) and may alert the therapist(s) to
expectations and assumptions that may not be met during the typical
course of cognitive therapy.
THERAPIST 1: (After explaining the ground rules) Maybe we can start off by going
over each individual's reasons for being here. One of the things I've found
over and over is that people do not have common reasons for coming into
agroup and it's important that we all understand what our particular goals
are. If someone is willing to start we can then go around the group and find
out from each of you what you hope to have happen as a result of being in this
group and how you think being in the group might help you to attain those
goals.
MARY: I've been married 35 years and have three grown sons. My husband is a
traveling businessman and I'm left alone quite a bit. I depend on my husband
a great deal and I do not like it that he is gone so much of the time. I woke up
one morning and felt that everything was closing in on me, and I took a bottle
of sleeping pills. I wanted to die because the future doesn't hold anything
good for me because my husband will always be traveling.
THERAPIST 1: So what goals do you want to be working on?
MARY: I'd like to know what to do with my life, yet I have no real desire to do
anything with it. I don't know how to get started .... I've lllways wanted to
do volunteer work, but I did do volunteer work before and you have to be in
at a certain time. I just can't get out of bed early enough so that I could do that.
THERAPIST 1: Okay, so one of the things you're saying is a problem with
motivation.
MARY: Motivation and I have been depressed practically all of my life and I think
that is because of my family situation.
THERAPIST 1: One of the things we will be talking about later is the cause of
depression but for now why don't we just say that you have some ideas about
what might be causing the depression and we'll take that a little further later.
Are there any other goals that you have?
MARY: I want to get out of depression and I want to do something but I don't
have that motivation like you said.
THERAPIST 1: How about you, Irene?
IRENE: Why I came here? Because you asked me to.
THERAPIST 1: What are your goals?
IRENE: Well, I'd like to be able to feel like I can get up and go to work and deal
with everyday situations.
THERAPIST 1: So it sounds like, similar to Mary, getting the motivation to go out
every day and having more self-confidence. Is there anything else?
IRENE: No.
THERAPIST 1: June?
JUNE: I guess I just want to stop being unhappy. The unhappiness has been
extreme for a while and though I have been receiving treatment I feel that my
symptoms have remained extreme and I came here as a result of looking for
other help. I want to stop being tired, I want to stop being unhappy, I want to
stop feeling discouraged.
THERAPIST 1: Okay. Bonnie, what are your goals?
BONNIE: I guess learning how to cope with depression without completely going
to pieces. You know, I realize that everyone at certain times of their lives get
depressed but some people know how to handle it better, you know, without
sitting around crying and going to bed. I think by talking to other people this
might help me to get a clearer view and understand it better.
THERAPIST 1: I have some goals as well and one of the major goals is to see each
and every one of you learn a little bit about yourself and also learn how to
cope with depression. Every group I have participated in I have found some-
thing that helps me personally and professionally and I'm looking forward to
that as well.
Patients frequently come into a therapy situation with some notion

of how well they will fare in treatment and of how treatment is likely to
progress. With depressed patients such expectations typically are pessi-
mistic, so eliciting an expression of these from each patient often dem-
onstrates how negative self-appraisals operate. For example, near the
end of the first session for a new therapy group, one of the authors
asked each participant separately to rank all group members, including
themselves, in terms of whom they thought would benefit the most
from the group. All participants put themselves at the bottom of their
own list. In the discussion that followed, it became clear that some very
striking similarities existed in terms of how participants tended to view

themselves vis-a-vis the others. Such thoughts as "Nobody else is as
depressed (or as hopeless) as I am," "Everyone else seems so normal;
I'm really messed up," and "This approach may work for some of the
others, but my depression is caused by my husband (or my job, being
out of work, my illness, etc.); the way I think has nothing to do with it,"
were typical. Pointing out the real similarity in the ways they thought
about themselves and their situations facilitated the identification of
their negative cognitive distortions.
Depressed people often are surprised when they see that other
depressed people experience similar situations and think about them-
selves in similar ways. Group settings often are an excellent opportunity
for participants to begin to view the situations they find themselves in
and the thoughts they have about themselves as common to depressed
persons. This knowledge may be helpful to them in learning to identify
their negative cognitive distortions and subsequently treat them as
symptoms of depression that they can work to alleviate.
In subsequent sessions this time may be used profitably as an op-
portunity for participants to react to the previous week's session and
report any thoughts they may have had about something that was said
or happened during that session. This allows the therapist(s) to monitor
how group participants are reacting to what is happening in the ses-
sions. Depressed persons often construe experiences in idiosyncratic
and negative ways. If the therapist is able to identify examples of this
process from the group session, the group then can explore discrepan-
cies among participants in how that incident was interpreted. This offers
an excellent example of how different meanings may be attached to the
same stimuli and how a negative construction may not be as accurate or
widely shared as a depressed person initially might think.
Initial Statements of Individual Problems
After assessing expectations it often is interesting and helpful to go

around the group again asking participants to share what they believe to
be the precipitating and/or contributing factors to their depressions.
Depressed clients often have some ideas about what might be causing
their depression and it is useful to give clients an opportunity to share
their explanations before introducing a cognitive explanation for depres-
sion. Once the therapist has listened to a client's explanation, the client
might be less resistant to considering an alternative explanation for his
or her depression. In addition the therapist may be given enough infor-
mation about an individual's circumstances in order that he or she can
draw on examples from these statements to present a plausible alterna-

tive explanation for that person's depression.
THERAPIST: What I'd like to go over now is exactly what you feel is contributing
to your feeling of depression and lack of self-confidence, fatigue, or whatever
you are experiencing. This will help give us some understanding of things
that are going on in your life as an individual that may be contributing to your
depression.
MARY: I've been to a psychiatrist for many years and have tried to be honest with
him. You want to know what the cause of my depression is, is that what it is?
THERAPIST: As you see it.
MARY: Well, the biggest reason for my depression is my husband traveling and
he can't give it up. I am left along from Tuesday until Saturday morning. I
have no friends and I don't want to burden myself onto my neighbors or my
children and I cannot have my husband stop traveling cause that's our bread
and butter. I think that's my biggest reason for my depression. When he is
home, even though he is working in his office which is in our house, I don't
like it but I'm satisfied just to have have him there so I can walk in and see
him. Basically, I have wrapped my life around him and that's what my private
psychiatrist said, that I have to let go. But I don't want to let go because I love
my husband and I want to spend as much time with him as I can. Although I
know he can't be with me during the day, at night I miss him tremendously
and I don't sleep well when he's away ...
THERAPIST: Do you think that the sleeping problem can be tied up with
depression?
MARY: Well, you see when I go to bed at night I think that I'm sleeping in my
bed and my husband is sleeping alone in a hotel room and I say why can't we
be together, why me? I just can't cope with things like I used to when my
children were little . . . those days I was able to tackle anything. I was a real
fighter and as I'm getting older I'm not the fighter I used to be. You see, I have
a heredity for mental illness. My mother was put in a mental institution when
I was 17. And I see I'm falling into the same pattern in my life. I don't want to
and I'm trying to fight it but I don't have that fight that I had when my
children were little. I'm afraid of the future, I'm afraid of being left alone.
THERAPIST: There are a number of things you bring up that I think we will be able
to get into and maybe clarify further. Irene, do you have any ideas about what
is causing your depression?
IRENE: My father was like that, he had a breakdown when I was 20 years old and
I feel like I'm a lot like him. He jumps at little things and then he's real cool. I
guess I'm the same way.
JUNE: My mother is very ill. She is in her 80s and has been in and out of homes
and hospitals ... and she is getting worse everyday. All of that is very de-
pressing and I think everyone has a perfect right to be depressed about those
things .... I don't have a lot of hobbies and my husband's job is not the best,
but I don't think that any of those things by themselves are enough to make
you give in. Somehow maybe you don't have to give in and that's what I'd like
to find. I hope that I can ... there will always be problems but only recently
have they seemed to close in on me and I can't even get out of bed in the
morning. My only hope is to believe that there is a way out and that I will find
it.
BONNIE: Well, it seems to me that everyone has given reasons for why they're
depressed and I really have no reasons. My mother or father was never
depressed; my family life is fine. There's no real reason for me to feel that way
or get really down. You know, like it's amazing you wonder why is this
happening you know, your life is perfectly fine ... there is really nothing
that I can point to, it just seemed to creep up on me.
THERAPIST: Nothing you've found yet.
BONNIE: No.
Presenting Cognitive Theory and Technique

Cognitive therapy makes several explicit statements about the na-
ture of the relationship between events, ideation, and subsequent affect
and behavior. Once group participants have been given a chance to
identify their problems the therapist(s) introduce an alternative way of
viewing their depression. He or she encourages them to begin examin-
ing the way they look at things and helps them to recognize the role of
how they view things in making them depressed.
THERAPIST: Let me tell you about an idea that many people who treat depressed
people, including myself, believe very strongly. That is that you don't neces-
sarily have to have an external thing happen to you to make you depressed.
One of the things that we've found over and over again is that the way a
person thinks is the closest thing that causes his or her depression and one of
the things we're going to be asking you to do is to keep a record of things that
you think are associated with any sort of feelings of depression or any other
negative thoughts that you might have. So what I'd like you to think about is
perhaps it isn't necessarily things that are happening outside of you that make
you depressed but things you think that make you depressed.
BONNIE: The way we perceive them.
THERAPIST: Okay, the way we perceive them and maybe, June, I can use your
example. I think what you're saying is that there can be all sorts of events that
go on and that maybe happened 5 years ago, 2 months ago, or 20 years ago. It
may be that you're best in forgetting those particular events or things that
have gone on that are unpleasant or that you had difficulty coping with. But
what I maintain is that until you change the way that you perceive things and
the way that you think about situations then the chances are that what you are
facing now you are going to be facing over and over and over again. No matter
what the stress is at the time, whether it is the loss of a parent or a problem in
a relationship or losing a job or whatever, all of these things can be depressing
but they don't necessarily lead to the depression that some of you have been
experiencing. There has to be a key in there and what we refer to this as is the
ABC's of depression. A being the event that is outside of you, the situation;
the C being the feeling that you have, the depression, the unhappiness, the
sadness; and the B being the ideas, the way you perceive things, and the way
you think about things.
It is useful to present a statement of the cognitive model as in the

above vignette and whenever possible tie the concepts to examples aris-
ing from the patients' presentation of problems. For instance, in this
case, the therapist would have done well to draw from the rich clinical
material provided by Mary. In fact, in her presentation she even re-
ported the cognitions she had when lying in bed at night. Thus the
therapist might have outlined for the group the ABC's of what occurs for
Mary when she goes to bed alone. For instance, the exchange might
havegone like this:
THERAPIST: Mary, when you were telling us about what you perceive to be the
factors precipitating your depression you mentioned what I thought was a
particularly good example of the way the ABC model works. I wonder if we
might go back to the example of what happens on nights when your husband
is on the road and try to outline that in ABC terms.
MARY: Well, like I was telling you, my husband is gone from Tuesday until
Saturday morning and at night I miss him tremendously and I feel so lonely
because none of my children are still at home and my husband is all I have.
THERAPIST: Let me interrupt you to note that it is usually feeling states, like
loneliness, or sadness, or feeling like we want to cry that alerts us that an ABC
chain of situation, cognitions, and emotions is occurring. Since we are usually
most aware of our emotions, we can use these as a cue to kick into the process
of investigating the situation we are in and the thoughts we are having in
order to discover why we are feeling the way we are. So, if we were to draw
three columns on the chalkboard for our A's (situation), B's (cognitions),
andC's (emotions) we can begin by filling "lonely" into Column C, the feel-
ings column. What other feelings did you have, Mary?
MARY: Well, like I said, I miss him tremendously.
THERAPIST: When we say we miss somebody sometimes that is more of a clue to
the kinds of thoughts we are having than an actual emotion. A good clue to
whether something belongs in Column C as an emotion is if we can say "I feel
_ _ _,"such as I feel lonely or I feel sad or I feel happy. Did you have any
other feelings the last time this situation occurred?
MARY: I felt sad and I guess I felt hopeless cause I know that my husband will
always be traveling and I will always be left alone.
THERAPIST: It sounds like there are some cognitions creeping in there but let's
hold off on those for a minute. We'll add sad and hopeless to the emotions
column and then let's switch over to Column A and fill in the situation. Can
you tell us where you were when these feelings occurred?
MARY: It always happens on nights when my husband is on the road and I'm
home alone.
THERAPIST: Okay, good. Now tell me again when it is that you begin feeling
especially lonely.
MARY: After I have gotten ready for bed and I lay down and I'm just lying there
because I can't go to sleep.
THERAPIST: (Writing this under A, situation, on the board) Okay, now we have a
good reconstruction of what the situation was and we put that inthe A col-
umn. When you were telling us earlier you mentioned some specific thoughts
that went through your mind as you were lying there. Can you tell us again
what those were?
MARY: I think about my husband sleeping alone in some hotel room and I'm
sleeping alone in my bed and I wonder why we can't be together, why me?
THERAPIST: (Writing these cognitions on the board under A) You've given us a good
string of cognitions there and I'm interested in the last one you mentioned,
"Why me?" Can you tell us more about that?
MARY: Well, I feel as though it's not fair because I've wrapped my life around my
husband and now that my children are gone, I just can't cope like I used to.
THERAPIST: And what does that mean to you?
MARY: I'm not the fighter I used to be and I'm afraid of the future, I'm afraid of
being left alone.
THERAPIST: Okay, let's stop there and review the string of cognitions. We refer to
these as automatic thoughts because of the way they occur in a rapid, auto-
matic fashion, seemingly without our having much control over them.
At this point the therapist might go through the string of cognitions

with the group and point out how they become increasingly global and
ominous in their implications. It also might be useful to poll group
members to see how many would experience similar emotions and be
unable to fall asleep if they were to lie in bed thinking those same
thoughts. The therapist can comment on how quickly this whole process
usually occurs and how it will take a special effort initially to be able to
reconstruct the situation and cognitions leading to a feeling state. But,
he or she can point out, expending the time and effort necessary to do so
will facilitate greatly the process of learning how to intervene in the
process, the goal being to short-circuit the run of automatic thoughts
and avoid subsequent negative feeling states. The main point is that the
therapist is likely to get a lot of mileage out of one or more good exam-
ples, especially if they arise from the group and the therapist can use the
example(s) to involve participants in a discussion of the ABC model.
Trying the Cognitive Model on for Size

Once the therapist has had the opportunity to make an initial pre-
sentation of the cognitive model, it is useful to turn the floor over to the
group participants to react to aspects of the cognitive model that they
perceive to be particularly applicable to their personal lives. We recom-
mend giving patients a copy of the pamphlet Coping with Depression
(Beck & Greenberg, 1974) to read before they come to the first group
session. This pamphlet does a nice job of introducing the cognitive
model and providing examples of typical ways in which depressed peo-
ple think about things that help maintain their depressions. This time
serves as a good opportunity to elicit group participants' reactions to this
material as well.
THERAPIST: I hope you've all had a chance to read Coping with Depression. I'd like
to spend some time now to talk about the parts of Coping with Depression and
the ABCs that we've talked about here today that you think might apply to
you and the parts that don't apply to you. What parts do you find apply to
you?
MARY: Everything. Every part of the book applies to me and my husband took
me to see a movie ...
THERAPIST 2: (At the first chance) To focus back on the pamphlet for a moment,
given that everything was right down main line center for you, what things in
it would you have particularly keyed on, what things particularly applied?
MARY: Well, the tiredness, the fatigue, the motivation, urn ... I can't ... if I
had the book in front of me I could . . . I read it twice and itseemed like it was
witten for me.
THERAPIST 1: How about the thinking aspect, one of the things the pamphlet
talks about is the way people interpret things in a negative way sometimes
and tend to exaggerate things.
MARY: Yes, I do. I make it worse than it really is or I exaggerate, and I have this
fear of going out at night which stems, I think, to my childhood .... I have
tried, I have gotten dressed and gone to the garage door and I turn around
and go back because I think I will be raped or robbed or somebody will grab
me and that would set me mentally out of my mind .... I'm a prisoner in my
own home; I don't know how to overcome this and I'd like to overcome it just
like I'd like to overcome my depression.
THERAPIST: The pamphlet talks about the association between situations and the
thoughts that we have in those situations. Do you see how that applies to
your experience, such as in the example you just gave?
MARY: Yes, like I have a cousin that just had a finger taken off because she has
cancer and that just sent me mentally wild.
THERAPIST: How about you, Irene, does that idea of the association between
thinking and depression have any meaning for you? Do you understand that?
IRENE: Yeah. As soon as you read parts of the book you recognize situations
you've been in and your reactions to them.
THERAPIST: Can you describe one of those situations for us?

IRENE: Yeah, a really indicative thing happened to me the other day. My little
girl (she's 10 years old) and I were sitting down on New Year's Day to write
dates and appointments on the new calendar. We were doing the family dates
and I was making up the one that I keep for the family and there was a lot of
cross referencing. Although I often feel like I can't do things, I guess I am
pretty efficient over the long haul and my husband even remarks that he
rarely misses any important dates because I'm so organized. Even while I was
doing this I was thinking I'm getting a lot done and I was feeling good about
that. Anyway, at one point I had to check a date and my daughter laughed
and she said "Oh, mommy, you're so inefficient." For just an instant I almost
went into a terrible fury and I thought "She doesn't appreciate anything I do"
and blah, blah, blah and I had to get up and I walked out into the kitchen and
all I could think was this was one of the bad times and I have to keep the lid
on. It wasn't real good, but I did. My daughter didn't mean anything by her
remark, she's a child and she's at the age where she wants to joke and laugh
the way adults do and she didn't mean it. It was me. I was convinced that I
had to defend myself; that I have to prove that I'm useful; that I'm doing
worthwhile things. I can analyze it now but I couldn't then. All I knew at the
time was that I was flying into this unreasonable rage and I wanted to stop
and I was able to by telling myself over and over this is one of the bad times,
but I ended up feeling miserable for a while.
THERAPIST 2: That's a very nice example. It sounds like you really got into what
you were thinking.
IRENE: Well, I didn't get the analysis until we sat here talking now.
THERAPIST 2: Can you apply the ABC way of looking at things to that situation?
IRENE: All right, the event is what she said, which seemed to me to be belittling
or it wasn't so much that she was belittling as it seems to me she really pointed
to something that's true, that I'm really not efficient ... and all I knew is that
I could feel this terrible rage coming on and I could not analyze any of these
thoughts at the time.
THERAPIST 2: So then, in terms of the ABC's ...
IRENE: Well, A was what she said and it was my reaction to it that she thinks I
really am inefficient and confused and I have to defend myself to prove that
I'm not.
THERAPIST 2: Okay, so A was what she said and C was your rage reactions, but
the B was "I really am efficient" and "I am going to have to prove ... "
IRENE: Yes! That's really what it was, yes.
THERAPIST 2: That's a very nice example of how that process works.
THERAPIST 1: Right, it's that whole idea that thinking and depression are really
tied together and it might not necessarily be exterior things that arecausing
the depression. It's what you think.
In this vignette both Mary and Irene came up with good examples.
In Irene's case the therapist was able to encourage her to think back to
that situation and outline the cognitions that intervened between the
situation and her subsequent emotional reaction. As we can see from

this example, it initially can be very difficult for persons to reconstruct
situations in terms of the ABC model. Therapist(s) need to take a very
active role early on to help group participants do this.
A similar technique involves asking participants to recall a specific
recent situation in which they became upset or depressed. The partici-
pant is then asked to try to recall the cognitions that he or she was
having in that situation and to make an association between the
thoughts and the affect he or she experienced as per the ABC model.
Clients often can recall situations in which they reacted emotionally
but cannot identify the cognition they were having in the situation. It is
usually helpful to ask them to reconstruct the situation as carefully as
they can and try to put themselves back into the situation as if they were
living it over. This often will make it easier for them to recall thoughts
that were triggered in response to specific environmental stimuli. If a
participant still is unable to come up with the thoughts that were occur-
ring, the therapist can call upon the group to generate a list of cognitions
that possibly might have occurred in the situation. If that original partici-
pant provides situation and background information, other group mem-
bers may be good at helping to identify possible cognitions. One or more
might then be recognized by the client, who initially was unable to come
up with them on his or her own.
As an example, there was a woman in one of the author's previous
groups who was attending night classes to become a disc jockey. She
reported in a group session that she had missed her last class session
and. had felt badly about that. When asked why she had missed class she
said she had decided at the last minute not to go because she had not
completed her homework for that week. Instead she sat at home that
evening and felt depressed. She was unable to identify what her cogni-
tions were that might have kept her from going to class or that were
associated with her subsequent depressed mood. She was able to pro-
vide some additional information, however, that was useful in helping
other group members speculate what her cognitions might have been. It
turned out that the class was being taught by some very prominent local
disc jockeys. She felt that she could not make a fool of herself in front of
people whom she admired and she imagined she would do just that by
going to class without having completed her homework. In addition,
she apparently had been doing well and several of the instructors had
mentioned to her that she was one of their best students. This made it
even more difficult for her to go to class unprepared because she
thought they would find out that she was not as good a student as they
originally had thought. Not surprisingly, the cognitions associated with
her feeling depressed while sitting at home were centered around her
chastizing herself for not having done her homework, thereby causing
herself to miss an important class session. In addition, she allowed
herself to believe that she would fall into disfavor for missing class, she
would not continue to do well in the course because she had fallen
behind, and that this was another example of a failure in her life.
We have found that it is often is easier for people to identify and
work with other people's automatic thoughts and distorted beliefs than
it is to deal with their own. Creating a situation in which participants can
help other participants deal with their cognitions serves as a "power
test" to find out what their capabilities are. Clients may be surprised that
they are able to act as therapists with others' cognitions although they
are less successful at working with their own. Such an observation can
provide for an interesting discussion of the factors involved that might
explain such a discrepancy and which, if intentionally manipulated,
might improve one's own typical performance. A participant may learn,
for instance, to avoid competing negative cognitions that interfere with
his or her ability to stay as task focused when attending to his or her
own cognitions as when helping others.
In summary, it is useful to get participants involved early in at-
tempting to relate cognitive formulations to their personal experience. In
a group setting the possible therapeutic interactions are multiplied. The
therapist(s) only need remain alert to opportunities to involve actively
one or more group members in a learning or teaching role.
Identifying and Testing Dysfunctional Beliefs

In the preceding section, we gave some examples of identifying
automatic thoughts. We mentioned that it is useful to focus on occasions
in which the client experienced an unpleasant emotion and then try to
reconstruct the situation. Once the situation is clearly in mind (which
may require that the client actively imagine himself or herself in it) the
therapist asks the client to attempt to recapture the thoughts that were
occurring. The therapist attempts to draw the client out in reporting
those thoughts because the most upsetting thoughts often occur later in
the chain. Those latter cognitions usually take the form of dysfunctional
beliefs that are implied by the automatic thoughts that precede them in
the chain.
The first session or two may be devoted largely to teaching partici-
pants to identify and report their automatic thoughts. Once they have
become familiar with this process the notion of evaluating those
thoughts can be introduced. The therapist(s) might choose to introduce
the rationale for the cognitive technique of evaluating one's own

thoughts and beliefs by first asking group participants what has helped
in the past to bring them out of a depressed mood. Depressed persons
often will report that it is helpful to have someone talk to them, es-
pecially in a reassuring or supportive way, even if it only provides a
distraction from their own thoughts.
In the latter case the therapist(s) can point to the benefit of distract-
ing oneself as further evidence of the important role cognitions play in
contributing to depressed affect. The therapist also can acknowledge
that it is often helpful for a client to talk with someone about the things
that are bothering him. Often this is because the reassurance and sup-
port given the client help relieve his concerns that he is a failure, unlova-
ble, worthless, and so forth. This relief is short-lived, however, and
depressed persons find themselves seeking constant reassurance and
support from others. In addition to being difficult for the depressed
person's family and friends, such continuing requests for support and
reassurance often result in the depressed person feeling guilty and more
depressed. However, depressed people can learn to do for themselves
what others have been only partially successful at doing for them in the
past. Just as they think things that make them depressed, they can learn
to think and view situations in ways that will help them feel better.
As with all cognitive techniques there are many ways in which they
can be presented to produce the desired effect. The following vignette
illustrates one way in which the therapist might introduce belief testing.
THERAPIST 1: Up until now we have largely focused on recognizing the negative

thoughts that we have in situations. We have even had you recording some of
those thoughts when they occur. Earlier we mentioned that depressed per-
sons could learn to examine their beliefs in ways which would help them
become less depressed. I'd like to focus now on techniques that you can use
when you catch yourself thinking automatic thoughts. The first thing we must
learn to do is to take the role of a skeptical observer in looking at our thoughts.
You'll find that if you first step back and attempt to distance yourself from the
thoughts it will be easier to look at them more objectively. Some people
pretend that the thoughts they are having are those of a friend who is coming
to them for help. Distancing ourselves in this way helps us to avoid taking our
negative thoughts at face value.
If a friend were to tell you that she was worthless and not liked, you
probably would not accept that. You would want her to give you good reasons
why she believed that to be true. Yet, when you think those thoughts about
yourself, if you are like most depressed people, you don't demand the same
kind of proof that you would demand of a friend before you'd believe their
negative thoughts and beliefs. So, the first thing you need to do when you
catch yourself thinking automatic thoughts is to stop and say something like,
"That's something I believe but it is not an established fact." Another thing

you might tell yourself when you are thinking about something that might or
might not happen in the future is "That's a prediction I am making about the
future but I do not know that it will turn out that way." In both cases the idea
is that we need to recognize that our thoughts are not necessarily true or valid
and we need to evaluate them before we accept them. I think it would be
helpful if we could tie some of what I'm saying into an example from one of
your experiences. Bonnie, when we were setting our agenda for today, you
mentioned that one of the things you wanted to talk about is your concerns
about being elected president of your women's club. Can you tell us what
some of those concerns are?
BONNIE: Well, I guess basically I don't believe that I'll be able to do it.
THERAPIST 1: What is it that you don't think you will be able to do?
BONNIE: I don't think I will be a good president.
THERAPIST 1: Okay, so your biggest concern is that you will not do a good job as
president of the women's club, is that right?
BONNIE: Yes.
THERAPIST 1: That is a good example of a prediction that you are making. If you
believe that to be a forgone conclusion rather than a prediction on which you
will have to wait and see, I would imagine that might be pretty upsetting.
BONNIE: It is whenever I think about it.
THERAPIST 1: It is a difficult belief to evaluate as it stands, however, because just
saying you're concerned about being president doesn't tell us what in particu-
lar you are concerned about. I'm wondering if it is some of the things that are
expected of you as president rather than just being president that has you
concerned. What I'm suggesting is that we often need to break down our
beliefs into specifics if we are to be able to really understand them and evalu-
ate their validity. What is there about being president that particularly con-
cerns you?
BONNIE: As president I'm in charge of coming up with programs for our monthly
meetings and that's what worries me the most.
THERAPIST 1: What does that involve?
BONNIE: I have to come up with ideas for topics and arrange for speakers.
THERAPIST 1: What about having to do that concerns you?
BONNIE: I don't think I will be able to come up with any good ideas.
THERAPIST 1: Okay, that's a good example of a negative prediction that is defined
well enough that we can evaluate it to see if that's a reasonable thing for you
to believe. Before we do that I'd like to write on the board three questions that
often are useful to ask in evaluating a negative thought or belief. They are:
(Writes on board)
1. What's my evidence?
2. Is there any other way of looking at that?
3. Even if it is true, is it as bad as it seems?
There are times when you may need to ask additional kinds of questions
and times you may not need to ask all of these but these three offer a good
general approach to evaluating our negative beliefs. The first "What's my

evidence?" is usually a good one to start off asking yourself. Bonnie, what is
your evidence for your belief that you won't have any good ideas; what makes
you believe that will be the case?
BONNIE: Well, I was made president-elect last month and I haven't had any ideas
yet. In fact, every time I think about it I just get anxious about not having done
anything yet.
THERAPIST 1: It sounds like part of why you believe you won't be able to come up
with any good ideas is that you haven't thus far. I have found this to be a
common reason that depressed people give for why they believe they won't
be able to do something.
THERAPIST 2: It is an interesting notion that past performance perfectly predicts
future performances. Can anyone in the group think of an occasion on which
they initially had difficulty learning how to do something that they eventually
mastered.
JUNE: Like learning how to ride a bike?
THERAPIST 2: That's a good example. Most people I know of didn't learn how to
ride a bike the first day they tried.
JUNE: I know I didn't.
THERAPIST 2: If you were to have predicted whether you would be able to ride a
bike successfully on the basis of your first try what would you have predicted?
JUNE: That I wouldn't be able to.
THERAPIST 2: Bonnie, how would learning how to ride a bike be similar to your
situation involving coming up with good ideas?
BONNIE: Well, maybe since I wasn't able to come up with any ideas the first time,
I think I won't be able to.
THERAPIST 2: Does it seem reasonable to you that you would feel anxious if you
were predicting that you would not be able to come up with any good ideas?
BONNIE: Yes, I can see how that would make me feel anxious.
THERAPIST 2: When you consider the analogy of riding a bike, how reasonable is
it for you to believe that you won't be able to come up with any good ideas on
the basis of not having been able to when you first tried?
BONNIE: Well, I suppose that would be kind of dumb but it seems like whenever
I think about it I don't have any ideas.
THERAPIST 2: Uh uh. What happens when you think about it.
BONNIE: I get anxious.
THERAPIST 2: Do you get anxious right away or only after you've thought about it
for a while?
BONNIE: At first I would get anxious only after I thought I about it a while, but
now I get anxious right away.
THERAPIST 2: To relate that back to riding a bike, how many times would you say
you actually got on the bike and tried to ride it and how many times did you
just get so anxious you didn't even get on the bike?
BONNIE: You mean how many times did I actually think about who I might get
for speakers? I suppose twice. The other times I just got so anxious I couldn't
think about it.
CoGNITIVE THERAPY FOR DEPRESSION IN GROUPS 35
THERAPIST 2: Altogether, how many minutes do you think you have spent actu-
ally thinking about what would be interesting topics or who would be good
speakers?
BONNIE: I suppose about 15 minutes, 10 the first time and 5 the second.
THERAPIST 2: It sounds like your belief that you can't come up with any ideas is
based on the fact that you haven't thus far. Perhaps this is a good opportunity
to ask the second of the three questions that we introduced earlier. (Points to
board) Is there another way of explaining why you haven't come up with any
good ideas other than that you can't? I wonder if you have been so focused on
your inability to come up with any ideas and have become so anxious when-
ever you think about it that you have not been able to focus on the task.
BONNIE: Yeah, you could be right.
THERAPIST 2: If you look at it in that way, does it mean that you don't have the
ability to come up with good ideas or is it more likely that the negative
predictions you have been making and the anxiety you've been feeling have
prevented you from being able to concentrate on the task?
BONNIE: I think I haven't given myself much of a chance.
THERAPIST 2: I think you're right.
THERAPIST 1: The third question we could focus on is what the implications
would be if it were the case that you couldn't come up with any good ideas.
Depressed people often don't ask themselves this question because they as-
sume the consequences would be so bad that they don't even want to think
about it. What do you think would happen, Bonnie, if you weren't able to
come up with any good ideas for topics or speakers?
We will leave our vignette here, but it should be noted that it usu-
ally is not difficult to address all three questions and it often is helpful to
do so. More or less time may be spent on any one, however, as the
situation dictates. After the group becomes more familiar with this pro-
cess it can be beneficial to enlist other group participants as co-thera-
pists. So as to make that less threatening it can be introduced as a well
established fact that people usually are better at detecting the un-
founded inferences that others are making and evaluating others'
thoughts and beliefs than they are their own. That is why it is helpful to
have others assist us by pointing out when we overlook something or
when we encounter a blind spot. Of course, in addition to helping one
another overcome past obstacles, it is a useful experience to view objec-
tively and help correct the kinds of errors in thinking that we all are
prone to.
Assigning Homework
By the end of a session, each member of the group should have

been assigned at least one explicitly planned activity to execute before
the next session. Initially, the assignment typically will involve some
sort of self-monitoring in which clients record their activities and their
mood each hour of the day. This kind of record can provide some in-
teresting information about what clients are doing with their time,
which activities are associated with increased moods, and which times
are their worst.
There is some evidence to suggest that it is very important that self-
monitoring be done on an hourly rather than daily basis (Evans & Hol-
lon, 1979). When depressed people report their mood retrospectively,
for instance at the end of the day, their report may be negatively biased,
inaccurately reflecting lower moods than actually were experienced. De-
pressed people often report in session that they experienced pervasive
low moods or that they do not find any activities enjoyable, even ones
that used to give them pleasure. These statements often are not sup-
ported by the mood ratings they make. When possible, portions of a
self-monitoring record might be displayed to the group to assess
whether they would agree to such a statement based on the ratings.
With severely depressed patients it may be necessary to plan an
activity schedule with them that they can follow through the week.
Sometimes less severe patients have particular difficulties only at certain
times of the day or week. For them it may be helpful to schedule ac-
tivities selectively during those periods.
A useful cognitive-behavioral technique involves the planning of
"experiments" for clients to carry out between sessions. The purpose of
these is usually to test out beliefs that require the client to gather more
evidence outside of the group. After a session or two, greater emphasis
is placed on regularly monitoring cognitions that are associated with
negative affect. Once clients become adept at recognizing these situa-
tions and identifying their automatic thoughts and dysfunctional beliefs,
they are encouraged to evaluate those beliefs and attempt to respond
rationally to them. One of the main goals of cognitive-behavioral thera-
PY is to enable clients to intervene successfully with their negative
thoughts when they occur. Incorporating techniques such as the triple-
column record in evaluating beliefs hopefully increases the likelihood
that these skills will be learned, maintained, and employed when they
would be useful.
It is good practice to assign new homework only as previous assign-
ments are mastered. In addition, even a homework failure can be turned
to therapeutic advantage if the time is devoted to discussing the reasons
for the failure. We like to convey homework as a no-loss proposition
from which the patient is likely to learn something no matter what
happens. Also, it is very important that the therapist actively attend to
assignments at the next session. Reviewing homework is an item that

the therapist always adds to the agenda. As we noted earlier, failure to
do so undermines the motivation to continue utilizing various tech-
niques between sessions.
Summarizing Session and Eliciting Feedback

Summarizing the main points of the session is a particularly good
way of increasing the probability that group members will apply cogni-
tive ways of looking at their thoughts and experiences outside the ses-
sions. Whenever possible, it is desirable to have participants do the
summarizing. In addition to increasing their active involvement in the
session, it gives the therapist an opportunity to assess how well partici-
pants are assimilating points made in the session. The therapist also
may rephrase or amplify clients' statements about the material covered.
Summarizing also may be employed profitably in the midst of sessions,
especially before moving on to a new topic.
Finally, it is important to give participants a chance to express any
reactions they may have had to things that were said or done in the
session. Given the potential for depressed patients to misinterpret or
react negatively to the actions of others, remarks made to them, and so
forth, it is important to attend to their occurrence and use it to demon-
strate cognitive evaluative processes.
Subsequent Sessions
Much of the structure adopted in the initial session is carried over
into subsequent sessions. We routinely begin each session by assessing
level of depression, asking for copies of all homework, and setting a
working agenda, usually utilizing that sequential inquiry of each patient
described previously. The bulk of the session often is devoted to select-
ing one or more agenda items from each patient and demonstrating the
application of cognitive change procedures. Particular care is given to
reviewing homework generated or experiments attempted between
sessions.
In early sessions, for closed groups, or whenever a new client is
added for open groups, the initial emphasis typically is on obtaining
behavioral change. Clients are encouraged to try things that they do not
anticipate working, generally presented as "an experiment," with an
eye to generating concrete evidence to counter dysfunctional beliefs.
After one or two such sessions, the focus typically shifts to a greater
emphasis on more purely cognitive procedures. Particularly useful is the

Dysfunctional Thoughts Record (DTR), a no-carbon-required tablet
(NCR tablets automatically reproduce multiple copies of written mate-
rials without requiring the insertion of carbon paper) printed to provide
columns for situations, feelings, thoughts, rational restructuring, and
subsequent feelings (see Beck et al., 1979; Hollon & Beck, 1979). This
does not mean that behavior change is ignored. Rather, attention to
specific acts or concrete counts is heavily relied on in the hypothesis
testing proceeds.
Generally, after about six to eight sessions group members are be-
coming fairly adept at using self-monitoring, behavioral, and cognitive
change techniques. They also should be showing at least initial signs of
symptom relief. 1
During these later sessions, we begin to pull for the clients underly-
ing assumptions, world views that, in and of themselves, do not pro-
duce depressions but which, when stimulated by events, seem to make
the individual susceptible to becoming depressed. Such assumptions
often must be extrapolated from repetitious automatic thoughts. In our
experience, it is rare for a client to be able to formulate an underlying
assumption. This is the point when historical reconstruction can prove
helpful; for example, "Can you remember when you first felt that way?
What was going on for you? What were you thinking?" As before, this
stage does not represent a clean break in the sense that behavioral and
earlier cognitive change techniques are discontinued. Rather, efforts to
identify more generalized assumptions are integrated into those on-
going endeavors.
Specific Management Problems

Any of a variety of specific managements problems that are not
typically encountered in individual sessions can arise readily in group
contexts. Examples include efforts to monopolize group time by one or
more members, lapsing into small talk, personal attacks by one member
on another, the development of subgroups, and the development of
different improvement rates. In general, these problems can be handled
IOur experience suggests that even the most depressed patients typically can learn and
utilize these procedures. We are less likely to be concerned about someone who is not
attempting and/or not using these techniques than the occasional patient who works
hard and diligently but seems to receive no relief. For the former patient we examine our
teaching styles or look for idiosyncratic blocks to learning. For the latter patient, we look
to other types of therapy.
COGNITIVE TIIERAPY FOR DEPRESSION IN GROUPS 39
readily if the therapist is willing to take the initiative and keep the group
focused on productive material.
SUMMARY
Overall, group cognitive therapy appears to be a viable option, even

at this relatively early stage of its development. The approach certainly
already has generated more evidence of specific efficacy than have many
other approaches in more widespread clinical use. Group cognitive ther-
apy for depression, like individual cognitive therapy for depression, is
problem focused and heavily structured. Great attention is paid to iden-
tifying and testing dysfunctional beliefs. The basis therapeutic stance is
educative; the therapists have a discrete body of theory and technique
that they wish to impact. Based on early returns, it appears that such
efforts are likely to meet with clinically meaningful success.ln this chap-
ter, we have attempted to outline what we have seen done in the past
and have speculated as to why it appears to work. Much more clinical
and experimental work remains to be done before we can feel comfort-
able with our level of understanding. Even now, however, it appears
that the types of approaches described can provide a powerful means of
combating depression in a group format.
AcKNOWLEDGMENTS
The authors wish to express their appreciation to V. B. Tuason,

Head, Department of Psychiatry, St. Paul-Ramsey Medical Center, for
his support; to Robert J. DeRubeis for his comments on an earlier ver-
sion of this chapter; and to Mary Jones for typing it.
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Living, 1974. (Pamphlet)
Beck, A. T., & Shaw, B. F. Cognitive approaches to depression. In A. Ellis & R. Grieger
(Eds.), Handbook of rational-emotive therapy. New York: Springer,1977.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, G. Cognitive therapy for depression: A
treatment manual. New York: Guilford, 1979.
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J. E., & Erbaugh, J. K. An inventory for
measuring depression. Archives of General Psychiatry, 1961, 4,561-571.
Blaney, P. H. The effectiveness of cognitive and behavioral therapies. In L. P. Rehm (Ed.),
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Christie, G. L. Group psychotherapy in private practice. Australian and New Zealand Journal
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Covi, L., Lipman, R. S., Derogatis, L. R., Smith, J. E., & Pattison, J. H. Drugs and group
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Emery, G., Hollon, S. D., & Bedrosian, R. C. New directions in cognitive therapy: A casebook.
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Friedman, A. S. Interaction of drug therapy with marital therapy in depressed patients.
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Gioe, V. J. Cognitive modification and positive group experience as a treatment for treat-
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75-28, 219)
Hollon, S. D. Comparisons and combinations with alternative approaches. In L. P. Rehm
(Ed.), Behavior therapy for depression: Present status and future directions. New York:
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Hollon, S. D., & Beck, A. T. Cognitive therapy for depression. In P. C. Kendall & S. D.
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Hollon, S. D., Bedrosian, R. C., & Beck, A. T. Combined cognitive-pharmaco-therapy versus
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Hollon, S. D., & Kendall, P. C. Cognitive self-statements in depression: Development of
an automatic thoughts questionnaire. Cognitive Therapy and Research, 1980, 4, 383-396.
Hollon, S. D., & Shaw, B. F. Group cognitive therapy for depressed patients. In A. T.
Beck, A. J. Rush, B. F. Shaw, & G. Emery (Eds.), Cognitive therapy for depression: A
treatment manual. New York: Guilford, 1979.
Klerman, G. L., DiMascio, A., Weissman, M., Prusoff, B., Paykel, E. S. Treatment of
depression by drugs and psychotherapy. American Journal of Psychiatry, 1974,131,
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Unpublished manuscript, University of Western Ontario,1978.
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3
Rational-Emotive Therapy in
Groups
RICHARD L. WESSLER
Rational-emotive therapy (RET) as group psychotherapy began almost

as early as individual RET. In 1955, Albert Ellis, who had been trained as
a psychoanalyst and who already was well known as a sex and marriage
counselor, became dissatisfied with the results he obtained from em-
ploying psychoanalytic principles. Therefore, he (Ellis, 1962) took the
bold step of directly confronting patients with their self-defeating phi-
losophies, of actively arguing against their ideas, and of assigning be-
havioral and cognitive homework for them to practice their newly
adopted ways of thinking and acting.
The goals of RET, whether done in groups or individually, are to
teach clients how to change their disordered emotionality and behavior
and to cope with almost any unfortunate event that may arise in their
lives. RET holds that humans can employ their conscious thought pro-
cesses to their own benefit by solving their problems and rethinking the
self-defeating assumptions about their own and other people's pre-
sumed perfectability.
The ideal outcome of RET would be for the individual to adopt an
attitude of self-acceptance rather than of self-judgment; to accept life's
realities, including grim realities, by acknowledging their existence and
not attempting to avoid or prevent them with magical thinking and
superstitious maneuvers. It would involve refraining from judging other
people in a global manner and especially from damning them for their
shortcomings and transgressions. It would mean independently think-
ing out for oneself an ethical philosophy rather than childishly depend-
ing upon other people or on religion for absolute rules about right and
RICHARD L. WEsSLER • Department of Psychology, Pace University, Pleasantville, New

York 10570.
43
44 RiCHARD L. WESSLER
wrong; unashamedly pursuing pleasure in both long-term and short-

term interests, rather than unpleasurably conforming to rigid rules, or
shortsightedly indulging oneself with no heed for the future.
RET seeks to help people reduce or eliminate strong negative emo-
tions (e.g., anxiety, depression, and hostility) so they can live more
personally satisfying lives. To accomplish this goal, RET seeks to help
people identify the beliefs that produce and sustain dysfunctional emo-
tional experiences and maladaptive behaviors and to change them to
beliefs that promote rather than thwart their personal objectives.
The goal of change, in other words, is an elegant philosophical
restructuring to enable the individual to pursue more efficiently the
common human goals of survival and happiness.
BAsic CoNCEPTS
The label Rational-Emotive Therapy refers to two different activities of

psychological therapists. First, the label stands for classical RET, charac-
terized by the extensive writings of Albert Ellis. In this form of RET,
neurotic disturbance is postulated to be caused by irrational thinking,
and the client is taught to identify his or her irrational thinking. The
process is highly directive, confrontive, and educative. It has been illus-
trated amply by Ellis in transcripts of therapy sessions (viz., Ellis, 1971)
and in tape recordings issued by the Institute for Rational Living in New
York City and in films and video tapes.
The second meaning of the label RET is co-extensive with the cogni-
tive-learning approaches to therapy. It has been called comprehensive
RET (Walen, DiGiuseppe, & Wessler, 1980) to distinguish it from classi-
cal RET. In this form of RET, neurotic disturbance is postulated to be
caused by irrational thinking as well as by faulty perceptions, muddled
inferences, arbitrary definitions, and illogical reasoning.
The classical version is highly philosophical in the sense that it
focuses explicitly on human values, on issues of right and wrong (i.e.,
morality), and a philosophy of living that includes tolerance for one's
imperfections, other people's transgressions, and the world's ample
supply of frustration.
Like classical RET, comprehensive RET is highly directive, confron-
tive, and educative; but it is in addition, persuasive and makes use of
techniques and procedures developed by cognitive learning and other
forms of treatment. It tends to be a good deal more eclectic, but without
losing the philosophic core that distinguishes RET from its allied ap-
proaches. Unfortunately, there are fewer examples of comprehensive
RATIONAL-EMOTIVE THERAPY IN GROUPS 45
RET available for reading, listening, and viewing. However, compre-

hensive RET is what most RET practitioners, including Albert Ellis, do,
especially in group therapy.
THERAPY
Theory
The theory of RET as a treatment of disturbance is quite simple: If a
person changes his or her irrational beliefs to rational beliefs, he or she
will suffer less and enjoy life more. The evaluation of self, of other
people, and of the world in general are the major targets of change.
RET treatment is based on an educational and persuasive model.
Clients are taught to identify how they are disturbing themselves by
uncovering their irrational beliefs, then they are informed about why
their beliefs are irrational and how to change them. If they change their
philosophical rules of living and then live according to those changes,
they will lead more satisfying and enjoyable lives. There is no assump-
tion that some deep or mysterious forces keep them from changing their
philosophy of living. People are postulated to have innate tendencies to
retain or readopt their irrational beliefs (Ellis, 1976), and because there is
widespread social approval for some of them, to readily retain those.
Since people often resist change or fail to change when new infor-
mation is presented to them, persuasive attempts other than informa-
tion giving are typical of RET sessions (Wessler & Ellis, 1980). These
persuasive attempts are better labeled dissuasive methods because their
aim is to help people give up their dysfunction! ones (Wessler & Wess-
ler, 1980).
Dissuasive methods are based on theories of attitude formation and
change. The evaluative component of attitudes is the particular target of
change because in RET the belief system consists of evaluations. Infor-
mation giving is directed at the knowledge component of an attitude,
but because many attitudes are not based upon knowledge, information
giving has its limitations.
Attitudes often are represented as having three components
(knowledge, evaluation, and action) in interdependent relationship. A
change in one may result in a change in the other two. A major theory of
attitude change, cognitive dissonance (Festinger, 1957), proposes that
changes in evaluations will follow changes in knowledge or action or
both. The RET theory of treatment makes use of this principle by offer-
ing arguments against rigidly held absolutistic beliefs and assigning
46 RICHARD L. WESSLER
homework between therapy sessions. Homework usually consists of the

client's doing something that is inconsistent with his or her beliefs and
thus inducing dissonance. As Festinger pointed out, it is difficult to
deny that you did something against your evaluative beliefs, especially
if there are witnesses. People tend to adjust their evaluative beliefs to fit
what they have done, or to fit what they have learned, or both.
Many other dissuasive maneuvers will be presented later in this
chapter. All can be understood as attempts to change attitudes. RET
does not depend upon rational discussion alone to produce therapeutic
change. In the broadest sense of RET, anything within the bounds of
professional ethics that helps people change their minds in favor of a
more personally satisfying philosophy of living is a legitimate part of
RET. RET assumes that the individual changes his or her own mind and
can choose to do so. It is not the therapist's responsibility to force
change.
Therapy Process
In broad outline, RET proceeds as follows: The individual identifies
explicitly or implicitly that he or she wants certain changes or goals. The
therapist shows the client that the goals of personal change can be
attained by cognitive change. The therapist goes on to show what the
client's maladaptive beliefs are and how they can be changed. The client
then can choose to work to change his or her thinking.
This simply stated process can occur over one session or many.
Some people never change much despite genuine efforts. (Why their
thinking is so difficult to change is not known, but Ellis suspects biolog-
ical diathesis.)
There is no assumption that any special relationship must be estab-
lished with the therapist before change can occur. The therapist exhibits
nondamning acceptance of the client, though he or she may express
judgments about some of the client's actions.
The therapist probably has to be seen in certain ways by the client in
order to be effective. The literature on attitude change and persuasion
(Karlins & Abelson, 1970; McGuire, 1969; Zimbardo & Ebbesen, 1969)
suggests some perceptions of the therapist that promote effective RET.
The therapist probably is more effective if seen as credible by the
client. A perception of credibility can be promoted by showing expertise
and trustworthiness. A confident manner and a belief in what he or she
says tend to communicate such expertise (cf. Frank, 1978), as do educa-
tional degrees and professional reputation. Trustworthiness may occur
when clients see therapists as genuinely interested in helping them and
not working for the therapist's sole benefit. The beginning of trust-
worthiness is to have genuine concern for the client's improvement and
welfare. The list of characteristics includes warmth, empathic ability,
and so forth.
The relationship with the client is important for another reason that
is unrelated to any presumed curative aspects. Therapist characteristics
that are irrelevant to the client's belief system probably influence accep-
tance of rational thinking. In other words, clients may change their
minds for reasons unrelated to logic and evidence presented to them.
Just as college students say they like a course or expect to do well
because they like the professor, clients may believe a therapist because
they like him or her or reject a therapeutic message be£ause they do not.
In group therapy the same concerns are multiplied. If the individual
does not like, respect, or believe the group members and the therapist,
the chances of his or her being helped are reduced greatly.
An issue in any group is its dynamics. Since the individual is the
focus of change in RET groups, dynamics are important insofar as they
affect the individual's thinking, feelings, and behaving. The norms of
the group, its communication patterns, and emerging leadership roles
can be used therapeutically or, if they encourage continued irrational
thinking, can function iatrogenically. Thus, in an RET group, cohesive-
ness is allowed, promoted, or discouraged, depending on whether the
therapeutic aims of the individuals in the group are helped or hindered
by group cohesiveness.
Group therapy provides opportunities for observing a client's in-
teractions and making comments about them. At times the teaching of
interpersonal skills is the chief concern of an RET group. This, however,
usually occurs in conjunction with or after attention has been given to
the client's belief system. For example, the teaching of assertive commu-
nication skills may aid a person in his or her everyday life, but by itself it
is a palliative. Assertive skills may help increase the chance for getting
what one wants, but that does not reduce exaggerating the unfairness of
not getting what one wants. Similarly, the improvement of communica-
tions skills between couples, so often cited by couples and counselors as
a serious difficulty, is a secondary aim in RET. The primary aim is to
reduce personal disturbance; then the couple can be shown how to
improve communications.
Treatment Tactics
The initial considerations in the process of RET in groups are the
same as with individuals. The individual is the focus of change and,
therefore, an assessment of the individual's problems is necessary. As-

sessment here means understanding the cognitive dynamics-the per-
son's main rational and irrational beliefs and their resulting emotional
and behavioral consequences. Facts about the individual's social status,
marital status, birth-order, height, weight, and age are of little or no
importance in RET. To an extent, even the practical problems in a per-
son's life (the A's in the ABC model) are of little importance at least
initially. Later, after dealing with the belief system, the practical prob-
lems may be taken up.
The therapist who leads the group is in a better position than group
members to make an assessment of problem diagnosis in terms of the
ABC model. However, group members, as they learn the ABC model,
often become adept at spotting each others' irrational beliefs and de-
fenses. There is the risk that group members may tacitly agree not to
confront each other or to offer only practical problem-solving sug-
gestions, but an experienced leader-therapist will recognize such ac-
tions, comment on them, and try to prevent their recurrence.
In order to make an assessment or problem diagnosis, the therapist
and group members actively ask questions, probe answers, offer com-
ments, and test hypotheses inferred from a focal client's in-group behav-
ior and self-reports of thoughts, feelings, and actions. The general strat-
egy is to follow the ABC model. The focal client, in presenting a personal
problem, usually starts with the A or activating experience. Then the C
or emotional consequences are sought and clarified. Sometimes both A
and C are revealed in the initial presentation of a specific problem, for
example, "I got very angry at my boss when he asked me to work
overtime last night!" In this illustration the individual identifies the A
(the boss's asking the person to work overtime) and C (hostility). The
group members, led by the therapist, then may ask questions about both
A and C, for example, "What reasons did the boss give?" (an A probe);
"Did you have something else to do?" (another A probe); "Has this
happened very often?" (yet another A probe).
And, "Did you let him know you were angry?" (C probe); "How
did you know it was anger that you experienced?" (another C probe).
These questions clarify and add richness to the report and are especially
helpful if the client has difficulty recognizing and reporting emotional
experiences, as is sometimes the case.
The therapist then leads the group in focusing on the belief system.
Using the model of anger presented earlier in this chapter, the therapist
asks questions about the demands the client placed upon the boss's
behavior ("He must not ask me to work overtime"), blame ("and he's a
rotten bastard for making such a request"), intolerance ("he shouldn't
have a responsible position if he's going to make such requests"), and

grandiosity ("he has no right to ask me to work overtime"). One by one
the client's evaluative thinking about the situation would be uncovered.
He or she might be asked to challenge the truth of the self-statements or
the group members might offer reasons why the self-statements were
untrue.
In addition to the approach of presenting personal problems, RET
groups also may be experiential. Group exercises adopted from many
sources may be used to "produce" emotional consequences. The follow-
ing exercise easily might be used with a new group; its purpose is to
"produce" emotional consequences (usually anxiety); to expose de-
fenses; to introduce the notion that thinking, especially evaluative think-
ing, largely determines emotional experiences; and that a great deal of
such thinking is automatically done without much awareness. The
therapist addresses the group:
I'm going to ask you to think of some secret, something about yourself that
you normally would not tell anyone else. It might be something you have
done in the past, something you're doing now in the present. Some secret
habit or physical characteristic. (Pause) Are you thinking about it? (Pause)
Good. Now I'm going to ask someone to tell the group what they have
thought of ... to describe it in some detail. (Short pause) But since I know
everyone would want to do this, and we don't have enough time to get
everyone in, I'll select someone. (Pause-looking around the group) Yes, I think
I have someone in mind. (Pause) But before I call on that person, let me ask
what are you experiencing right now?
Answers such as tense, anxious, and nervous are commonly men-

tioned. Ideas such as "I hope you don't call on me!" are expressed. At
this point the therapist shows the group that it is the thought of doing
something, not the doing itself, that leads to their feelings. The therapist
then asks questions about what kinds of thoughts led to these feelings.
Typical responses are: "If they would find out something about me I
wouldn't want them to know, that would be awful!" Once the discus-
sion has begun, it often picks up momentum as people realize that their
strongly evaluative thinking about what might happen led to their anx-
ious reactions. As the discussion progresses, the therapist can show the
group members that they may be demanding that they follow social
norms implicit in the situation, for example, "I must do what the leader
says." The anxiety-producing conclusions are obvious: "And if I don't
do what he says, he and the others will think that I've copped out or
can't take it or have some other weakness. That would be awful and
prove what a worthless person I truly am!"
Further discussion may show people their defensiveness and self-
protectiveness. For example, some people will admit that they would
not have revealed anything too embarassing, just something that
sounds risky but really is "safe." Others will admit that they thought of
leaving the room. Such responses often are generalized to other situa-
tions as well and can be uncovered by asking, "Is your reaction typical
of the way you usually act when put on the spot?"
An imaginative RET group leader can incorporate almost any exer-
cise into the process. The "secret" is how the experience is processed,
not how it is conducted. Any experience or exercise intended to gener-
ate "here-and-now" feelings can be processed using the ABC model.
And, of course, awareness of one's belief system or insights into one's
behavior is not the end of the processing of an experience. Dissuasion-
helping the person change dysfunctional evaluative thinking-is the
crucial activity.
Nardi (1979) has combined elements of psychodrama with RET. For
example, a group member playing another member's parent shouts irra-
tional beliefs and hits the focal person with a foam rubber bat; then the
focal client takes the bat and hits him or herself while shouting the same
beliefs. Although this exercise overstates the importance of early so-
cializing agents in acquiring of irrational beliefs, it is an effective demon-
stration of what the client does today to create his or her own misery. In
another psychodrama-inspired exercise, group members acting as alter
egos speak the irrational beliefs of the main characters in a psycho-
drama; this exercise gives members opportunities to clarify what irra-
tional thinking is and how it affects behavior.
Didactic exercises can teach RET principles, such as the following
demonstration created by the author to teach the notion of human com-
plexity and the illegitimacy of self-evaluation. It is most conveniently
introduced after a client's saying some self-deprecating remark. The
therapist says, "Before we respond to John's remark, I'd like to ask
everybody to do something for me. Do you see this table? I'd like some-
one to measure it for me." If no one responds, he asks someone, es-
pecially John, to attempt the task. Ambitious group members will report
the table's length, width, height, or weight. None of this is accepted by
the therapist. It is not the length, width, height, or weight that is of
interest, but the table itself. Of course, there is no way to measure the
table itself; partis par toto, the part-whole error in self-evaluation can
then be discussed: to measure one's whole worth on the basis of a few
dimensions is illegitimate, a form of self-prejudice. Humans, of course,
are considerably more complex than tables.
Cognitive and behavioral rehearsal, especially in the form of role
playing, readily may be used in an RET group. The group often provides
a "safe" environment in which to try out new behaviors acquired

through skill training and to reinforce new rational ways of thinking.
When a client's problems involves a good deal of interpersonal anxiety,
the group provides a forum to try out interpersonal skills; more impor-
tantly, it provides a forum for attacking the shame that in RET theory is
at the heart of interpersonal anxiety. Shame is hypothesized to occur as
one fearfully anticipates or experiences real or attributed criticism by
other people of one's weaknesses. In the group one can learn not to feel
shame about any of his or her characteristics and can work at improving
those characteristics that can be modified.
To summarize, the initial activity in the rational-emotive therapy
process is assessment of the individual's problem. To do this, questions
are framed in a way that yields information to support or refute the
hypotheses about the individual's cognitive dynamics as formulated by
the therapist and group members. The next step is to make the indi-
vidual aware of how he or she is creating self-sabotaging emotional and
behavioral consequences. The next step is dissuasion, any activity
intended to help the individual change his or her maladaptive, unrealis-
tic, irrational beliefs to ones that promote individual survival and happi-
ness. The two most common approaches are (1) educational and (2)
direct and indirect methods of influence. The principle direct methods
are Socratic dialog and logical disputation. When direct methods do not
seem to be effective, indirect methods may be used.
Homework has been a characteristic part of RET since its inception.
Its use in groups differs little from its use with individuals. The client
agrees to do some activity during the time between sessions. The ac-
tivity might be reading RET literature (bibliotherapy), writing out chal-
lenges to his or her irrational thinking (written homework), or some
shame-attacking or risk-taking experiential assignment.
To aid in getting rid of irrational ideas that lead to shame (interper-
sonal anxiety over real or fictitious inadequacy), the client is asked to do
something foolish in public. The violation of social norms is an effective
shame-attacking exercise. For example, most people seem unaware that
they conform to custom when riding elevators and almost always face
the front of the elevator, even though they are not sure whether it is
illegal not to do so. A shame-attacking exercise, then, would consist of
asking someone who says he or she would feel anxious riding in eleva-
tors while facing the back instead of the front, to do so. Anticipation can
be probed; people may have images of the other passengers giving them
strange looks or thinking that the deviant was crazy or stupid. The
therapist can show that looks or thoughts cannot directly affect anyone,
and even spoken words are ineffective unless taken seriously.
The RET practitioner urges shame-attacking experiences for yet an-

other reason. Even if the client has correctly interpreted the meaning of
people's glances or read their minds accurately, it is the B or belief
system that leads most directly to the anxiety. Thus, one's evaluative
philosophy about harmlessly breaking social rules and receiving crit-
icism for so doing is the main concern of this exercise. RET teaches self-
acceptance-to follow one's own conscience despite others' disap-
proval. Thus, the shame-attacking exercise is aimed at increasing self-
acceptance and mature responsibility, not simply at achieving comfort
while doing a specific zany activity. Although these exercises often are
humorous because they involve harmless social rule breaking, they have
a serious purpose. Shame-attacking exercises can be done not only with-
in the group but also as an assignment to all group members to perform
outside the group and to report during the next group meeting.
The risk-taking exercise is any activity that the individual defines as
"a risk." Since the risk referred to is psychological, what is risky is both
idiosyncratic and objectively nondangerous. Thus, in the final analysis,
it is not truly a risk, but the discovery of this fact is a main purpose of
risk-taking exercises. A man who fears striking up conversations with
women may be asked to do so. A person who "must" do everything
perfectly is asked to make mistakes. Through their experience, if they
carry out the activity, they learn that their dire prophecies do not come
to pass, that the anticipation is worse than the doing, and that what they
have done once they can do again, thus building confidence.
These activities are assigned with the person's consent. The group
often can exert influence on the individual to do the assignment and can
provide a forum for rehearsal and practice. It is important to note that
the group may misunderstand the shame-attacking and risk-taking
homework assignments. The point is not to do them well nor to over-
come uncomfortable situations by gaining mastery over them. The point
is to gain mastery over oneself by actively confronting self-limiting phi-
losophies of living. Thus, the woman who refuses to initiate contacts
with men because she would feel worthless if she were rejected is en-
couraged to approach men not because she can become better at it with
time and thereby escape rejection, but to accept herself even if she re-
ceives rejections. In fact, were she to approach men and not receive
rejections, an experienced RET therapist might comment, "That's too
bad. Try again!" These exercises are deliberately couterphobic because it
is one of the best ways to overcome irrational thinking about life's
"horrors."
Consistent with the aim of risk taking, the RET group leader does
not try to create a climate of support in which people are reinforced for
their neurotic "need" for love and approval. Group members are en-
couraged to adopt and express nonjudgmental attitudes toward each
other, to practice what Ellis calls nondamning acceptance. This is some-
what different from positive regard and is closer to affective neutrality.
Given time and the freedom to communicate with each other, group
members often develop warm feelings and cohesiveness even though
these sentiments have not been promoted by the leader. So, although
some initial attempts to encourage people to reveal personal facts and to
"trust" each other are desirable to get the group started, their continued
use is seldom necessary.
The whole issue of trust, which some group members (and some
therapists, too) overemphasize, requires reassessment. Trust means
several things. First, that I can trust you with information about myself
and that you will not practically disadvantage me because of your priv-
ileged communication. This is essentially an ethical issue having to do
with confidentiality. Second, most clients worry about the psychological
harm they might suffer at the hands (or is it mouth?) of another person.
Since psychological reactions are of our own making, however, and
based upon our belief systems, there is in fact nothing to "trust" another
person with. Trust also means that I can trust you to help me. But this
issue, which is by far the more realistically important one, seldom is
mentioned in therapy groups.
Uncomfortable with strangers is another phrase that group mem-
bers use to justify remaining silent when actively working on their prob-
lems would be better for their purposes. Some people have a life philos-
ophy that says, "I must never feel uncomfortable," known in RET
jargon as low frustration tolerance of LFT. Both trust and uncomfortable
are socially respectable ways of labeling shame. They are better dealt
with as B's to be changed than as conditions the group has to fulfill. In
other words, speaking up about oneself is both a shame-attacking and
risk-taking experience. Clients are done a disservice when allowed to
avoid anxiety-provoking situations either within or outside the group.
PRACTICE
Problems
Almost all neurotic problems can be treated in an RET group. Psy-
chosis, whether of organic or of unknown origin, cannot be treated in an
RET group, but its sufferers frequently can benefit from working on
their neurotic problems or, more simply, on their problems of living.
It is better, then, to specify what cannot be treated in an RET group.

Psychosis itself, cannot be, but some of its symptoms, for example,
egocentric thinking can be by a vigorous leader and group members
who feel free to point out the self-centeredness. Disorders in which the
individual does not seek change are not appropriate for an RET group.
Some involuntary referrals can be "hooked" into therapy by showing
that RET can help them achieve some goals, but many cannot. Criminals
are not necessarily imprisoned because of neurosis. Although they stu-
pidly may think they can get away with crime in the long run, they
hardly are driven to commit it by anxiety, depression, or hostility. The
latter factors might be a reason in some cases, and the skillful therapist
might show how the criminal's life would be better without enraged
hostility; such persuasion would be a first step in eventually doing RET
with the law breaker.
Other involuntary referrals can be treated similarly: First, "moti-
vate" the client by showing that he or she can benefit in some way from
taking RET seriously. RET or any therapy is a means to an end; if the end
therapy can serve as one that is important to the person, he or she will
tend to see therapy as somewhat valuable. In involuntary referrals, the
therapist might be seen as the agent of society, and in fact may so act to
try to get the person to become the "standard" socially acceptable model
of a human. In this writer's opinion it is unethical to use therapy in this
way. It is the client's goals that we can work on, not society's. In fact,
RET often goes against societal norms and explicitly asks people to de-
cide for themselves what is right and wrong rather than passively ac-
cepting "society's" (or someone's version of "society's") rules. Over-
socialization creates neurosis. Undersocialization creates sociopathy,
but that, strictly speaking, falls outside the scope of RET.
Assessment
Precise differential diagnosis usually is not done in RET. Rough
categorization based on an initial individual interview is enough to
screen out persons who are blatantly psychotic, overly egocentered,
withdrawn to the point of perpetual silence, or talkative to the point of
compulsiveness. A psychotic individual would not be excluded because
of the psychosis, but because he or she might be too withdrawn or
otherwise unable to interact with other group members.
Evaluation of a different kind is done as the leader sorts through the
client's reports and actual behavior to discover the main irrational phi-
losophies he or she lives by. This is more discriminating than simply

asking a person about his or her troubles. If clients could report all of
their beliefs when asked, there would be little for therapists to do. But a
person with an anger problem over his or her boss's behavior may have
several problems, for example, putting him or herself down when the
boss treats him or her unfairly or taking the boss's unreasonable request
as a lack of respect and then "awfulizing" about that. We often get
angry at others because they say or do things that "cause" us to feel
ashamed or anxious. Within a few sessions, the RET leader can give
fairly complete accounts of each person's main life difficulties, belief
system, main symptoms, and how hard he or she works to change.
This last point, how hard the client works at change, is particularly
important. Most people can uncover or recognize their beliefs and can
understand how those beliefs are leading to upset and goal-defeating
behaviors. Som people, however, find it exceptionally difficult to over-
come their irrational thinking or to do what would help them effect
significant changes. It is one thing when an individual does not change
thought habits of a lifetime; this takes time and practice. It is quite
another when the person does not attempt to carry out behavior-experi-
ential homework assignments. The reason may be LFT or discomfort
anxiety.
When a person claims that something is too difficult or too inconve-
nient, he or she is expressing a philosophy of low frustration tolerance-
that life should not be so hard. Most people want to change easily and
comfortably. Others fear the discomfort they might experience in doing,
say, a risk-taking assignment. They want to feel better before changing,
instead of changing to feel better.
One of the important evaluation tasks of the therapist is to discover
what the person fears and to help reduce the fear before they attempt to
make significant behavioral changes. To accomplish this, imagery and
time projection can be employed: imagery to discover exactly what the
person fears and time projection to help him or her develop some confi-
dence to cope.
In one example, a young woman who refused to dance in public
despite the repeated requests from her husband to go to a disco reported
that she imagined everyone would laugh at her. Rather than reassure
her that this would not happen, the therapist asked her to imagine the
details: How many people would be there? Would they all laugh? Would
they laugh simultaneously or consecutively? How long would each
laugh? The therapist then deliberately exaggerated the scene and asked
her to imagine all 30 patrons consecutively laughing for 10 seconds. To
illustrate the length of a 10-second laugh, the therapist laughed for 10

seconds and was joined by the client in laughter during the last 3 sec-
onds. She was then asked if she could stand this "horrible torture" for
300 seconds and to imagine what it would be like. She decided that she
could stand it for 5 minutes even though she previously had been con-
vinced that she could not stand it at all. Armed with this cognitive
rehearsal she successfully carried out her homework assignment of
dancing in public and later used the same approach to overcome other
social phobias without the help of the therapist.
If it is apparent after a group has begun that one or more members
do not participate and seem unlikely to, they may be excused from the
group and referred for individual treatment. Each is there for help; if
they are neither giving nor getting help they would best be excused from
the group.
Treatment
The process and mechanisms of treatment have been described in
the previous section. In this section the beginning of a group will be
illustrated. Assume that the group members are unknown to each other
but have had an initial screening interview with the therapist.
The initial task is to get the group members acquainted with each
other. This can be accomplished by each person's simply saying his or
her name and mentioning a little about him or herself, or it can be the
focus of an exercise in which pairs get acquainted with each other, then
form larger groups.
An early issue is the trust one. It can be handled by the leader's
discussion of the issue or by an experiential exercise such as the one of
asking for "secrets." The "secrets exercise" also can be used to intro-
duce the ABC model.
Another introduction to the ABC model is one developed by this
writer and labeled the emotional dictionary. It is especially useful with
groups that are not accustomed to talking about their emotional experi-
ences. A chalkboard or other large writing surface is required. Group
members are asked to name common English words that stand for emo-
tions, which are listed on the board. If any controversies arise from the
choice of a word, they are discussed to discover common meanings (one
of the points of the exercise).
The group then is asked to vote on whether each word stands for a
negative or positive emotional experience (not whether it can have posi-
tive or negative outcomes). In case of doubt, the leader can ask, "Would
you look forward to experiencing (say) anxiety?" A plus or minus sign is

placed next to each word.
Then the group is asked to indicate whether the word stands for an
experience that is usually extreme and dysfunctional, or mild-to-moder-
ate, or perhaps even motivating. Again a vote is taken and disagree-
ments discussed. A 2 or 1 respectively is placed next to the algebraic sign
of each word. Then, the leader tells the group that in RET we make the
assumption that -2 emotions are due to iBs, and that -1 emotions are
due to rBs. Although this is something of an oversimplification, it pres-
ents the idea of discriminating rational from irrational beliefs and moti-
vating but negative emotions from goal-defeating ones.
The processing of additional exercises or personal problem solving
using the ABC model can be done with greater awareness on the part of
the group members. In all of RET there is an emphasis on the non-
mysterious: therapy and counseling are seen as educational and dissua-
sive processes without intentions or "insights" that must be concealed
from the cliend or carefully timed. If an individual client or group mem-
ber asks a question about theory, philosophy, or procedure, it is an-
swered unless the question is an obvious attempt to sidetrack the discus-
sion; even then, it might be answered and the discussion refocused on
the topic.
Treatment may be either time limited or open ended. Ellis's therapy
groups at the Institute for Rational-Emotive Therapy have been in exis-
tence for many years, with several complete turnovers of membership.
New members are incorporated rather easily into the group, partly be-
cause the leader discourages a "we-are-special" attitude among group
members, and partly because established group members seem eager to
work with new people.
Termination, as mentioned above, is a matter of individual deci-
sion, although both therapist and group members may comment on the
decision and even try to dissuade the individual from his or her choice if
further treatment seems warranted. Good questions for the therapist to
ask are: What are you not doing that you would like to do? And what are
you doing that you would like to stop? These concrete questions can
assist an individual in reviewing his or her own desire for further treat-
ment. Some clients remain in group long after they have ceased to create
significant problems in their lives, usually because they enjoy the group
experience and it helps them to keep their own thinking clear. When
obvious dependence on the group is detected, the therapist will move to
encourage greater independence, perhaps insisting that the person
leave the group. Termination in time-limited groups is not an issue in
RET.
Therapist's Tasks
The leader of an RET group is a therapist not a facilitator. The term
facilitator implies that the leader merely creates conditions for positive
growth potentials to become fulfilled. Since no positive growth poten-
tials thwarted by society or other people are assumed in RET theory, the
notion of facilitator is inappropriate.
Nor is the leader first among equals. His or her job is to provide
structure for group experience or problem-solving attempts. The clients,
of course, furnish the specific content.
The communication pattern in problem solving within groups is
one of therapist to focal client, with other group members either observ-
ing if the therapist is especially active or directing their messages to the
therapist or to the focal client. There is little interaction among nonfocal
clients in this situation.
Another communication pattern emerges when the therapist teach-
es inductively; most of the messages are exchanged between the thera-
pist and the other group members. Again, little interaction among the
group members occurs.
However, the therapist deliberately can withdraw from the discus-
sion and assume the role of coach rather than teacher-therapist. The
group members are left to process an exercise or attempt to apply the
ABC model to a focal client's problem. As long as the group does well
and remains on target, the therapist does not intervene. When the
group wanders or proposes practical solutions without attempting to
work with the individual's belief system, the therapist can redirect their
efforts. Simple comments such as "I wonder who can guess what John's
beliefs are that lead to his anger?" can redirect the discussion.
The therapist also is active in seeing that one or two people do not
dominate the discussion or that no one becomes disruptive. Since there
is no assumption in RET that anyone "has" to talk or has a "right" to be
heard, the therapist can manage the group discussion diplomatically
and head it into productive areas.
Group members may socialize with each other outside the therapy
sessions (and frequently do), but the therapist does not. The therapist's
relationship is professional not social. The therapist may see individuals
from the group for private sessions. Clients who require hospitalization
for psychosis or suicide attempts are referred to a suitable facility, and
their re-entry to the group is assessed upon their release. Occasionally,
clients may be referred for medication, and this practice could be a
condition for remaining in the group, depending on the attitude of the
specific RET therapist.
APPLICATION
Group Selection and Composition

There are no special rules regarding group selection. Some practical
guidelines are to exclude persons who are likely to be disruptive because
of active psychosis or compulsive talking and to include members of
both sexes, because many problems of interpersonal anxiety involve
relations with the opposite sex. These guidelines might be disregarded if
the person diagnosed psychotic were only occasionally disruptive or if
therapy were combined with consciousness raising, for example, in a
men's or women's sexuality group.
It is probably unwise to have all depressed persons in the same
group, although a group having the same phobia (e.g., flying) might
work well as a time-limited, topic-limited therapy group.
Group Setting
There are no special space requirements. A circular seating arrange-
ment facilitates interactive communications. Sufficient space for role
playing and psychodrama experiences also is desirable, and the space
should be private enough to preserve confidentiality.
Group Size
No special rules apply. If there are fewer than 6 group members,
discussions may lag. If there are more than about 12, it is difficult to
include everyone.
For the teaching of RET principles and illustrating their application
to selected problems, the group size could amount to several hundred.
Ellis frequently demonstrates the use of rational principles in daily life to
groups of 100 or more, although these demonstrations are not thought
to be group therapy. Similarly, the public education workshops held at
the Institute for Rational Living in New York City, Los Angeles, and
elsewhere may be attended by scores of people. These workshops lie
somewhere between therapy and education and focus on specific topics,
for example, overcoming creative blocks and designing future life goals
and plans.
Therapy Frequency, Length, Duration

Most RET groups meet weekly. They may be open ended with
changes in membership or time limited. For time-limited workshops,
about six to eight weeks seems typical. The length of session varies from
an hour and a half to three hours. An exception is an RET group mar-
athon, which might range from 10 to 14 hours or longer. There are no
prescriptive guidelines for frequency, length, or duration.
Media Usage
There are no restrictions or requirements for media in RET groups.
Videotape equipment might be used for giving feedback to participants
about their mannerisms and style of presentation, but this probably is
rarely done. Chalkboards and flip charts also could be used, but are not
required. "Props," for example, foam bats, might be used. Ellis has
conducted group therapy for years without any media aids, although he
uses printed homework forms that clients may fill out. Some RET thera-
pists (e.g., Maultsby, 1975) makes more extensive use of written forms.
Leader Qualifications
A leader should be professionally qualified to practice counseling
and/or psychotherapy in his or her state and be competent in conduct-
ing rational-emotive psychotherapy. Although many professionals may
meet these requirements and competently perform RET, certain ones are
recognized by the International Training Standards and Review Com-
mittee in RET as associate fellows and fellows. They have demonstrated
their abilities and are recognized as qualified in the practice of rational-
emotive methods.
Ethics
Practitioners of RET are bound by the ethical code of their respective
professional groups. The majority of recognized rational-emotive thera-
pists are psychologists bound by the ethical code of the American Psy-
chological Association. Violations of ethical standards also may be re-
ferred to the International Training Standards and Review Committee
for action if the professional is certified to practice rational-emotive
methods.
RESEARCH
There have been many research studies published that deal with
RET and other cognitive-learning approaches to psychotherapy. These
studies either focus on the cognitive hypothesis as a factor in psycho-

logical disturbance (Ellis, 1979), or therapeutic outcome studies (Di-
Giuseppe, Miller, & Trexler, 1979). Very few studies have investigated
group therapy per se.
In general, the studies cited in these summaries lend support to the
role of cognition in emotional-behavioral processes. The analog studies
support RET treatment claims about the efficacy of its interventions. The
problem with both these research summaries is that very few studies
investigate pure or classical RET.
The studies that Ellis (1979) cites in support of his theoretical claims
come from a wide variety of sources. Relatively few of them test hypoth-
eses specifically derived from RET theory. It seems safe to conclude from
the volume of studies cited by Ellis that cognitions play an important
role in human behavior and experience; that neurotic behavior is corre-
lated with unrealistic ideas and illogical thinking; and that mood is af-
fected by cognitive processes. However, the fundamental hypothesis of
RET-that irrational beliefs lead to self-defeating emotions and that ra-
tional beliefs do not-has not been adequately investigated.
The outcome studies of RET suffer from the same deficiency: few of
them have studied pure or classical RET as an independent variable.
DiGuiseppe et al. (1979) review about 50 studies, noting their limitations.
Some used no behavioral outcome measures, obtaining data only on
changes in irrational beliefs as measured by a paper-and-pencil test, a
practice Wessler (1976) warned against. Some study the outcome of
educational efforts, not psychotherapy or counseling. Others were stud-
ies that report outcomes of cognate approaches, not pure RET. Compre-
hensive RET is the kind actually practiced, and it overlaps significantly
with the approaches of Meichenbaum (1974), Beck (1976), and others.
Although some of the outcome research is impressive (especially Rush,
Beck, Kovacs, & Hollon, 1977), the therapy is not exclusive RET in
nature. The few RET studies support its effectiveness with such specific
problems as public-speaking anxiety and test-taking anxiety.
One difficulty in conducting research on RET, whether group or
individual, is that RET is not a single technique in the sense that, for
example, desensitization is. RET is a theory of disturbance that empha-
sizes the roles of maladaptive perceptions, misconceptions, and evalua-
tions. RET is a growing collection of tactics for helping people change
their maladaptive cognitions; some tactics are very direct, some indirect.
What makes research difficult is that a skilled RET therapist may use
several cognitive, behavioral, and affective-expressive tactics within a
few minutes while working with a client (Wessler & Ellis, 1980). If the
direct disputing of irrational beliefs seems to get nowhere, the therapist
quickly can switch to imagery or role reversal, or analogies, or even

parables and poetry. It is very difficult to duplicate this therapeutic
flexibility under controlled conditions.
If one accepts RET as an attitudinal theory of neurotic disturbance,
then a different research question emerges: namely, can attitudes be
influenced in dyads and larger groups? The answer is yes, and it is
supported by several decades of research in attitude change and persua-
sion. RET employs these tactics to bring about evaluative and other
cognitive changes (Wessler & Wessler, 1980).
STRENGTHS AND LIMITATIONS
RET takes the individual and his or her problems as its focus. It can
be used for specific problems, for example, a phobia, and thus functions
very much like behavior therapy. Or, it can take personality exploration
and self-awareness as its goal, as do traditional psychotherapy, non-
directive counseling, and other self-awareness approaches. As a system
of therapy, RET easily incorporates specific techniques developed in
other systems into its tactics of therapeutic dissuasion. Versatility and
applicability to a wide range of neurotic problems of living are among
RET's outstanding strengths.
RET is most easily used with clients who recognize their own re-
sponsibility in creating their difficulties or who readily come to accept
this fact. RET makes no claim that the person was a victim of his or her
parents, society, or past passive conditionings. Clients who wish to
become undisturbed, rather than discovering on whom to place blame
for disturbance, benefit most quickly.
RET works well with clients of at least average intelligence, but can
be used with other people in a more or less rote fashion (which is
probably how they learned their philosophy of living initially). Clients
who are rigidly religious often resist the humanistic ethical message
central to RET, but one need not give up all religion to do RET or to
benefit from it. Almost all religions offer a rational version that de-
emphasizes or eliminates the absolutistic thinking found in its very con-
versative or orthodox counterparts.
RET is no cure-all. It does not cure psychosis or psychopathy. It will
not stop crime, delinquency, or social problems. Since RET depends on
the cooperation of the client, it will not help the uncooperative. Thera-
pists may try to encourage cooperation by many means, including their
personal charisma, but not everyone is willing to cooperate.
Group RET has additional limits. The very disturbed client may be
better helped in individual sessions. A client whose activities require

weekly or more frequent monitoring would benefit more from indi-
vidual sessions than from group.
On the other hand, for certain clients, particularly shy ones, group
treatment is better than individual treatment. For many clients, the ad-
vantages of group therapy far outweigh the disadvantages. Most clients'
problems involve other people, and therefore the group is an ideal set-
ting in which to work on their problems. True, there is the disadvantage
that there will be lesser amounts of attention from the therapist, but the
advantages of group therapy are many:
1. They are cost efficient; the therapist can see several clients at
one time and teach rational principles to many people at one
time.
2. Members of the group can learn that they are not unique in
having a problem or in having specific kinds of problems.
3. The group can provide a forum for preventative psychotherapy
since members can hear others discussing problems that they
may not have faced or may not be currently facing in their lives.
4. Group members can learn to help each other. It is a well estab-
lished educational principle that one of the best ways to learn a
skill is to try to teach it to someone else. Clients learn rational
thinking while trying to teach it to others in a group setting.
5. Some experiences, activities, and exercises can be done only in
groups. The group also provides forum for practicing shame-
attacking or risk-taking exercises.
6. Some group exercises may be advantageous in bringing out
specific emotions that then can be dealt with in vivo in the group
setting.
7. Certain problems are more effectively dealt with in a group, for
example, interpersonal or social-skills deficits. The client can
practice new social behaviors and ways of relating to people.
8. A group setting allows clients to receive a great deal of feedback
about their behavior, which may be more persuasive in motivat-
ing them to change than that of a single therapist in an indi-
vidual situation.
9. When therapeutic efforts are focused on practical solutions to
life problems, the presence of many heads in a room may result
in more suggestions than an individual therapist could muster.
10. The group members can provide a source of peer pressure that
may be more effective in promoting compliance with home-
work assignments than that of the individual therapist.
Finally, the group can provide a phasing out experience for clients
who have been in individual therapy. Such clients may have discovered
their irrational ideas and how to dispute them but require additional
practice to complete the process.
REFERENCES
Beck, A. T. Cognitive therapy and the emotional disorders. New York: International Univer-
sities Press, 1976.
DiGiuseppe, R., Miller, N. J., & Trexler, L. D. A review of rational-emotive psychology
outcome studies. In A. Ellis & J. M. Whiteley (Eds.), Theoretical and empirical foundations
of rational-emotive therapy. Monterey, Calif.: Brooks/Cole, 1979.
Ellis, A. Grawth through reason. Palo Alto: Science and Behavior Books, 1971.
Ellis, A. The biological basis of irrational thinking. Journal of Individual Psychology, 1976, 32,
145-168.
(Eds.), Handbook of rational emotive therapy. New York: Springer, 1977.
Ellis, A. Rational-emotive therapy: Research data that support the clinical and personality
hypotheses of RET and other modes of cognitive-behavior therapy. In A. Ellis & J. M.
Whiteley (Eds.) Theoretical and empirical foundations of rational-emotive therapy. Mon-
terey, Calif.: Brooks/Cole, 1979.
Festinger, L. A theory of cognitive dissonance. Evanston, Ill.: Row, Peterson, 1957.
Frank, J. D. Psychotherapy and the human predicament. New York: Schocken, 1978.
Maultsby, M. C., Jr. Help yourself to happiness, New York: Institute for Rational Living,
1975.
McGuire, W. M. The nature of attitudes and attitude change. In G. L. Lindzey & E.
Aronson (Eds.), The handbook of social psychology (Vol. 2). Reading, Mass.: Addison-
Wesley, 1969.
Meichenbaum, D. H. Cognitive-behavior modification. Morristown: N.J.: General Learning
Press, 1974.
Nardi, T. J. The use of psychodrama in RET. Rational Living, 1979, 14 (1), 35-38.
Rush, A., Beck, A. T., Kovacs, M., & Hollon, S. Comparative efficacy of cognitive therapy
and pharmacotherapy in the treatment of depressed outpatients. Cognitive Therapy and
Research, 1977, 1, 1-8.
Walen, S., DiGiuseppe, R., & Wessler, R. L. A practitioner's guide to rational-emotive therapy.
New York: Oxford University Press, 1980.
Wessler, R. L. On measuring rationality. Rational Living, 1976, 11 (1), 25.
Wessler, R. L., & Ellis, A. Supervision in rational-emotive therapy. In A. K. Hess (Ed.),
Psychotherapy supervision. New York: Wiley-Interscience, 1980.
Wessler, R. A., & Wessler, R. L. The principles and practice of rational-emotive therapy. San
Francisco: Jossey-Bass, 1980.
Zimbardo, P., & Ebbesen, E.G. Influencing attitudes and changing behavior. Reading, Mass.:
Addison-Wesley, 1969.
ADDITIONAL READING
Arnold, M. B. Emotion and personality: Psychological aspects. New York: Columbia University
Press, 1960.
Berkowitz, L. Roots of aggression. New York: Atherton, 1969.
Davison, G., & Neale, J. Abnormal psychology: A cognitive experimental approach. New York:
Wiley, 1974.
Ellis, A. Humanistic psychotherapy: The rational-emotive approach. New York: Julian, 1973.
(Eds.), Handbook of rational emotive therapy. New York: Springer, 1977.
Ellis, A. Discomfort anxiety: A new cognitive behavioral construct. Rational Living, 1979,
14 (2), 1-7.
Ellis, A., & Geiger, R. Handbook of rational-emotive therapy. New York: Springer, 1977.
Ellis, A., & Harper, R. A. A new guide to rational living. Englewood Cliffs, N.J.: Prentice-
Hall, 1975.
Hauck, P. A. Overcoming depression. Philadelphia: Westminster, 1973.
Hauck, P. A. Overcoming frustration and anger. Philadelphia: Westminster, 1974.
Hauck, P. A. Overcoming worry and fear. Philadelphia: Westminster, 1975.
Horney, K. The neurotic personality for our time. New York: Norton, 1939.
Izard, C. E. Human emotions. New York, Plenum, 1977.
Karlins, M., & Abelson, N. I. Persuasion (2nd ed.) New York: Springer, 1970.
Katz, D., & Kahn, R. L. Social psychology of organizations (2nd ed.). New York: Wiley, 1978.
Knaus, W. J. Rational emotive education. New York: Institute for Rational Living, 1974.
Knaus, W. J. Do it now: How to stop procrastinating. Englewood Cliffs, N.J.: Prentice-Hall,
1979.
Lazarus, A. Multimodal behavior therapy. New York: Springer, 1976.
Lazarus, A. In the mind's eye. New York: Rawson Associates, 1977.
Lazarus, R. S. Psychological stress and the coping process. New York: McGraw Hill, 1966.
Mahoney, M. J. Reflections on the cognitive-learning trend in psychotherapy. American
Psychologist, January 1977, 32, 5-13.
Mahoney, M. J. A critical analysis of rational-emotive therapy and therapy. In A. Ellis & J.
M. Whiteley (Eds.), Theoretical and empirical foundations of rational-emotive therapy. Mon-
terey, Calif.: Brooks/Cole, 1979.
Moore, R. The E-priming of Albert Ellis. In J. Wolfe & E. Brand (Eds.), Twenty years of
rational-emotive therapy. New York: Institute for Rational Living, 1975.
Raimy, V. Misunderstandings of the self. San Francisco: Jossey-Bass, 1975.
Rimm, D. C., & Masters, J. C. Behavior therapy: Techniques and empirical findings. New York:
Academic, 1974.
Schachter, S., & Singer, J. E. Cognitive, social and physiological determinants of emotional
states. Psychological Review, 1962, 9, 379-399.
Watzlawick, P. The language of change: Elements of therapeutic communication. New York:
Basic, 1978.
4
Self-Control Group Therapy of
Depression
MICHAEL w. O'HARA AND LYNN p. REHM
The purpose of this chapter is to describe in some detail a self-control

therapy program for depression. To this end we will provide the ra-
tionale and context for the development of the treatment program. Sec-
ond, we will discuss briefly the model of depression on which the treat-
ment program is based. Third, will be a description of subject/client
characteristics. Fourth, the nature of the research support for the effec-
tiveness of this program will be indicated. Finally, we will describe on a
session-by-session basis the elements of the treatment program.
The self-control therapy program has evolved over the past seven
years in the context of five therapy outcome studies as well as trials in
various community mental health centers. The original therapy package
was developed by Fuchs and Rehm (1977) in an effort to determine the
efficacy of a treatment based on Rehm's (1977) self-control model of
depression.
SELF-CONTROL MODEL AND ITS IMPLICATIONS IN THE

THERAPY OF DEPRESSION
The self-control model of depression (Rehm, 1977) derived from a

more general model of self-regulation proposed by Kanfer (1970, 1971;
Kanfer & Karoly, 1972). The model describes the cognitive-behavioral
MICHAEL W. O'HARA • Department of Psychology, University of Iowa, Iowa City, Iowa

52242. LYNN P. REHM • Department of Psychology, University of Houston, Houston,
Texas 77004. Preparation of this chapter was supported in part by NIMH grant 2R01
MH27822 to Lynn P. Rehm.
67
68 MICHAEL w. O'HARA AND LYNN P. REHM
processes that maintain certain behaviors that lack environmental sup-

port. Thus, adaptive self-control functioning may explain behavioral
persistence despite environmental consequences that seem to mitigate
against it (e.g., dieting, quitting smoking, writing a book). The model
posits three interconnected processes (self-monitoring, self-evaluation,
and self-reinforcement) operating in a closed loop feedback system.
Self-monitoring refers to the observation of one's own behavior and
its situational antecedents and consequences. Self-evaluation involves a
comparison between an estimate of one's performance derived from
self-monitoring and an internal criterion. Rehm (1977) has elaborated
Kanfer and Karoly's model by considering the importance of causal
attribution in the self-evaluation phase. Positive and negative self-eval-
uations are mediated by the extent to which an individual attributes
causality for important outcomes to him or herself as opposed to exter-
nal factors over which he has little control. Self-reinforcement generally
refers to the self-application of overt or covert rewards and punishments
contingent upon positive or negative self-evaluations.
Rehm suggested that dysfunctions at any of these stages may be
implicated in the development of depression. Specifically, he identified
six self-control dysfunctions: (1) excessive monitoring of negative
events; (2) attention to immediate versus delayed consequences of be-
havior; (3) setting stringent standards in self-evaluation; (4) inaccurate
attributions of causality; (5) insufficient self-reward; and (6) excessive
self-punishment. Rehm (1981) has reviewed evidence that supports the
role of the various self-control dysfunctions in the etiology of depression
as well as the links between self-control dysfunctions and depressive
symptomatology.
Characteristics of depressed subjects who have benefited from self-
control therapy as well as documentation of the program's effectiveness
have been presented elsewhere (Fuchs & Rehm, 1977; Rehm, Fuchs,
Roth, Kornblith, & Romano, 1979; Rehm, Kornblith, O'Hara, Lam-
parski, Romano, & Volkin, 1981); however, we will summarize them
very briefly here. Subjects have been women ranging in age from late
teens to mid-fifties. They have been predominantly Caucasian and mid-
dle class; nevertheless, there has been considerable variability along the
lines of social class and race. Education level has varied from ninth grade
to the Ph.D. level with a median and mode around 12 to 13 years. About
60 to 70% of the subjects were married.
Subjects met stringent depression criteria in order to be admitted
into the therapy groups. Criteria have varied but in early studies sub-
jects were required to have had MMPI-depression scale scores of at least
70. In later studies a Beck Depression Inventory score (Beck, Ward,
SELF-CONTROL GROUP THERAPY OF DEPRESSION 69
Mendelson, Mock, & Erbaugh, 1961) of at least 20 was required. Subjects

in later studies also were required to meet Research Diagnostic Criteria
(Spitzer, Endicott, & Robins, 1978) for Major Affective Disorder. Though
subjects were solicited volunteers from the community, they were
equivalent in most respects to a moderately to severely depressed outpa-
tient population.
Five outcome studies have documented the effectiveness of the pro-
gram provided in between 6 and 12 sessions. A variety of control groups
have been employed including no treatment, nondirective group thera-
py, active instigational group therapy, and assertiveness training. A one
year follow-up of subjects from two early studies (Romano & Rehm,
1979) indicated a persistence of treatment effects.
APPLICATION OF SELF-CONTROL THERAPY
Self-control treatment programs have ranged in length from 6 to 12

sessions; all have followed the same basic sequence both within and
across sessions. Across sessions our strategy has been to focus on self-
monitoring, self-evaluation, and self-reinforcement in a sequential fash-
ion. The assumption is that each may be conceptualized as a therapy
module and that self-evaluation builds on self-monitoring, and that self-
reinforcement builds on self-evaluation. The number of sessions alloted
for each component may vary both as a function of the needs of the
clients and the exigencies of clinical practice.
Therapy sessions generally last between an hour and one half and
two hours. The beginning of each is devoted to two activities. Clients fill
out either a Depression Adjective Check List (Lubin, 1967), or the Beck
Depression Inventory and perhaps the Self-Control Questionnaire
(Rehm, et al., 1981). These periodic assessments of mood and self-con-
trol attitudes provide feedback on the progress of each client in therapy.
Following completion of self-report instruments, the therapist re-
views with the group homework assigned the previous week. This peri-
od of homework review fulfills several purposes. First, program com-
pliance readily may be assessed. Our basic assumption has always been
that compliance with therapeutic homework assignments is crucial to
the success of the group program. Group members typically have a
variety of experiences with their homework so that we encourage mem-
bers whose homework experience was positive·to share their successful
strategies with other group members. Members model appropriate self-
control behaviors for each other as well as providing support to each
other for making efforts at cognitive and behavioral change.
Our experience has been that the power of group therapy is most
evident during the review stage. Up to a third of the entire session may
be devoted to this process. A depressed client often does not believe he
or she can meet the goals the therapist has set for him or her. The group
allows the individual to interact with others who are similar in terms of
how they feel. As group members see each other making changes, their
own sense of hopelessness usually diminishes enough so that they try
out new ways of thinking and new behaviors. Despite the relatively
brief duration of these groups, a surprising degree of cohesion develops
as these women work together to overcome their depression.
Following homework review, new material is presented to the
group members didactically. The group switches to a psychoeducational
mode at this point. In each session the therapist will discuss an aspect of
depression from a self-control perspective. Each of the six self-control
dysfunctions are described over the course of the group program. The
therapist discusses how a particular dysfunction is causally related to
depression and what can be done to rectify the dysfunction. At this
stage it is important for the therapist to present the self-control rationale
in a convincing fashion since each group member is likely to have his or
her own understanding of the causes of his or her depression. Some-
times it is necessary to request that clients suspend belief and, in the
nature of an experiment, act as if our analysis of their depression is
congruent with their own. Again, group members, who have found that
changing their self-control strategies has an impact on their mood, also
will be helpful in influencing the belief system of doubting clients.
The group discusses the session's material both during and after the
therapist's presentation. The therapist especially encourages members
to provide examples from their own daily life as to how a particular self-
control dysfunction impacts on their thinking and behavior.
In order to illustrate and concretize the session rationale an in-
group exercise is completed. For example, during the week between the
first and second session group members are requested to monitor their
daily mood, positive self-statements, and activities. The exercise for the
second session is for clients to graph their daily mood ratings and daily
frequency of positive self-statements plus positive activities. What cli-
ents often observe doing this exercise is that the graphs are parallel,
indicating that their mood is related to the frequency of their positive
self-statements and activities.
The in-group exercises serve to clarify the didactic presentation as
well as to make the material more personally relevant. Group members
usually complete the exercises alone or with the help of the therapist.
Time is alloted in group to discuss any new learning resulting from the
exercises as well as any new confusion. The exercises also serve as a

preparation for the homework assignment that follows directly from
them.
The homework assignment is one of the most important elements of
the therapy group. Based on the material presented and the exercise,
homework is prescribed, the purpose of which is to encourage group
members to put into practice self-control concepts to which they have
been exposed in group. In the early stages of the group a therapist will
contact each group member by phone to assess compliance with home-
work instructions as well as to clear up any confusion from the previous
group. Given the relatively brief duration of the therapy program,
prompt assessment of client problems with homework is essential.
SELF-CONTROL THERAPY MANUAL
We will present the 10-session version of the self-control program

which includes three sessions each devoted to self-monitoring and self-
evaluation and two sessions each of self-reinforcement and program
review. The program will be described session by session following the
structure outlined above. Sections that are in quotes and are attributed
to the therapist are paraphrases only of material that is presented in
session. Dialogue that is presented is for illustration of points only.
Session 1: Self-Monitoring
The self-monitoring module is the base on which the rest of the
program is built. At the beginning of the session, the therapist presents
a general overview of the 10-session program. The presentation of the
program rationale might be presented in the following way.
THERAPIST: The therapy program in which you are going to participate probably
will differ from any previous experience that you have had with group thera-
PY· We will take a directive problem-solving approach to help you deal with
your depression. The program in many ways will be course-like and we will
be providing instruction, doing in-group exercises, and homework to help
you develop new cognitive and behavioral strategies for overcoming depres-
sion. Over the next 10 weeks, we will be working with one central idea and
that is that mood is related to your cognitions and your activities. You can
control your mood and depression by changing your cognitions as well as
your activities. We will help you to develop effective cognitive strategies as a
way of increasing both positive cognitions and activities. You also will learn
new goal-setting strategies as well as ways of motivating yourself toward

those goals.
Rationale. Three points form the basis of the first-session rationale:

(1) Mood is related to cognitions and activities. (2) Depressed persons
selectively attend to unpleasant events in their lives. (3) Learning to pay
more attention to pleasant events and increasing positive self-state-
ments and activities will help in overcoming depression. The first two
points are the principles around which the session revolves and the
third point describes what the clients do with the information. In every
session we elaborate points with examples and further explanation until
we believe that each client appreciates the significance of the point.
In developing the rationale that mood is related to cognitions and
activities we provide examples of their relationship.
THERAPIST: Both what we think about and what we do influence our mood.
Many of you have had the experience of feeling sad after thinking about a
personal failure or a family problem; or other times, for example, you may
have chastised yourself for some real or imagined failing such as being five
pounds overweight. The influence of thoughts on mood works the other way
as well. Thinking of a past success or pleasant experience often has the effect
of enhancing mood.
What we do also influences mood. For example, I'm sure you have all had
days when you started out feeling depressed, but several good things oc-
curred that left you in a good mood. You may have talked to a friend, had
pleasant interaction with one of your children, or a gratifying experience at
work. The reverse may happen as well; for example, an argument with a
friend can quickly ruin a positive mood state. In order to overcome depression
it is important to recognize the relationship between what you think and do
and your mood.
We attach a great deal of importance to the therapist presenting the

rationale convincingly. Clients come to therapy with a variety of notions
regarding their depression and we try to present our rationale so that
they will understand their depression in a way congruent with the pro-
gram. Removing the mystery of mood change also may be of value for
many clients. We provide "good reasons" for why they may be de-
pressed and offer strategies for change.
The second point of the rationale, "mood is also influenced by what
we attend to," is one of the crucial anchors of the program. Changes in
self-monitoring patterns often precede positive changes in mood. We
attempt to modify the way in which clients self-monitor their own posi-
tive and negative cognitions and events on a daily basis.
THERAPIST: I also want to stress that depressed persons often pay attention only
to the negative events in their life, ignoring positive ones. Imagine two per-
sons, both of whom experienced an equal mix of positive and negative events.
If one of the persons focused mainly on positive events and the other pri-
marily on negative events, we would have little doubt as to which person
would feel more depressed. Many depressed persons find it difficult to identi-
fy any positive experiences in their life.
The therapist encourages discussion of the first two points of ra-

tionale and prompts for examples from group members.
THERAPIST: Mrs. B., I noticed you seemed a little sad when I talked about attend-
ing to negative events. Would you share your thoughts with the rest of the
group?
MRS. B.: My life seems to be full of bad things. I have problems with my husband
and kids and even my own parents don't leave me alone. All I think about and
everything I do is unpleasant.
THERAPIST: From what you have said, you seem to believe that the difficulties
that you experience are causing you to feel down. Take a minute and think of
a pleasant interaction with a friend that occurred in the past month. How did
you feel?
MRS. B.: I can think of one and I felt good. I wasn't thinking of all my troubles. I
seemed to forget them.
One of the goals during group discussion is for clients to reframe

their current problems. The therapist would point out to Mrs. B. that she
does have positive experiences and that they do affect her mood. Point-
ing out to clients how the way they think and behave is related to
depression prepares them to accept our prescriptions for change.
The third point of rationale suggests the first stage in our strategy
for overcoming depression.
THERAPIST: Learning to pay more attention to positive events and increasing

cognitions and activities that bring up mood level will be our goal. By learning
that your mood is affected by what you do and how and what you think rather
than by uncontrollable forces, you will gain a sense of control over your
mood.
The initial interviews and first-session introductions provide infor-

mation for the therapist regarding what problems brought each client
into therapy. The therapist, whenever possible, reframes each client's
presenting complaints into our cognitive-behavioral framework and en-
courages the group members to do the same for each other.
Homework Assignment. In an earlier section we discussed the impor-

tance of the homework assignment. The therapist stresses that home-
work assignments are given at the end of each session and that they are
crucial to the success of this type of therapy.
THERAPIST: Your first assignment will be to start paying particular attention to

positive self-statements and activities. We want you also to observe how your
mood varies with the types and numbers of positive self-statements and ac-
tivities that you experience each day. You will have a chance to learn which
cognitions and behaviors are most important for you in determining your
mood.
Take a look at the log sheets and lists of examples of positive self-state-
ments and activities. The following principles should be employed in doing
your self-monitoring: (1) Keep the self-monitoring logs with you throughout
the day, and record as often as possible. Make sure that you have recorded all
your positive self-statements and activities in your log by the end of each day.
(2) Record in a few words the actual self-statement or activity. Emphasis
should be on trivial as well as large ones. (3) The lists should serve as a guide
for types of self-statements and activities you otherwise may have missed.
Review your list every now and then as a reminder. (4) At the end of each day
record your day's mood. Although it may not seem so, everyone's mood
varies from day to day and even from hour to hour. Try to rate your mood on
a scale from 0 to 10. Zero stands for the worst mood you have ever experi-
enced for a day and 10 stands for the happiest mood you have ever experi-
enced for a day. Use any and all points in between and remember to record
even small changes from one day to the next. (5) Use a separate log for each
day; more than one if you need. {6) Bring your logs to each session! The rest of
the program will build on this information.
We usually will ask group members to take a few minutes to recall

both trivial and important positive self-statements and activities from the
day. We emphasize paying attention to trivial activities and self-state-
ments (i.e., small, often-overlooked) so that the group members do not
wait around for a major positive event or an important positive self-
statement to occur in order to log something positive. When the thera-
pist is confident that all group members understand the logging pro-
cedure, he or she will let them know that they will be contacted by
phone during the week to check on their homework assignments and to
see if they are having any problems with them.
In the first session, time allocation is as follows for the 90-minute
group: (1) introductions by group members and therapist-30 minutes;
(2) program overview-S minutes; (3) session rationale-35 minutes;
and (4) homework assignment-20 minutes. Clinicians sometimes ques-
tion how necessary it is to stick to these time guidelines. The guidelines
TABLE 1
Positive Self-Statements and Activities List
Self-statements
1. I like people.
2. I really feel great.
3. People like me.
4. I've got more good things in life than the average person.
5. I deserve credit for trying hard.
6. That was a nice thing for me to do.
7. I'm a good person.
8. I have good self-control.
9. I am considerate of others.
10. Someday I'll look back on these days and smile.
11. My health is pretty good.
12. I am an open and sensitive person.
13. My experiences have prepared me well for the future.
14. I have worked long enough-now is time for fun.
15. Even though things are bad right now, they are bound to get better.
Activities
16. Planning something that you will enjoy
17. Going out for entertainment
18. Attending a social gathering
19. Playing a sport or game
20. Entertaining yourself at home (e.g., reading, listening to music, watching TV)
21. Doing something just for yourself (e.g., buying something, cooking something,
dressing comfortably)
22. Persisting at a difficult task
23. Doing a job well
24. Cooperating with someone else on a common task
25. Doing something special for someone else, generosity, going out of your way
26. Seeking out people (e.g., calling, stopping by, making a date or appointment,
going to a meeting)
27. Initiating conversation (e.g., store, party, class)
28. Playing with children or animals
29. Complimenting or praising someone
30. Showing physical affection or love
are somewhat arbitrary; nevertheless, they reflect our estimation of the

amount of time needed adequately to cover material and allow for group
discussion. Coverage of the entire first session material in the initial
meeting allows group members to start homework right away. Later
sessions may themselves be expanded as much as the clinician desires
and homework simply may be repeated. We might note at this point
that we have no data suggesting additional therapeutic value for groups,
on the average, as number of sessions increase from 7 to 12.
Day: _ _ _ _ __ Date: _ _ _ _ __
Po itive self-
statement or
Po itive self-statement activity
or activity list number
I.
2.
3.
4.
5.
6.
7_
9.
10.
11.
12.
13.
14.
15.
16.
17.
19.
20.
Day's mood rating: 0 2 3 4 5 6 7 8 9 10

unhappiest happie t
ever ever
FIG URE 1. Self-monitoring log.

Session 2: Mood and Events

The relationship between mood and self-statements and activities is
further developed in the second session. Clients have spent a week
monitoring positive self-statements and activities as well as rating their
mood on a daily basis. Sessions 2 through 10 begin with a review of the
previous week's homework as well as the rationale from the previous
session.
Homework Review. The therapist begins the session by reiterating
that mood is improved by increasing one's attention to positive self-
statements and activities and increasing them. Group members are en-
couraged to bring up any problems that they may have had in complet-
ing the self-monitoring assignment. Each subject is asked to report on
any positive experiences she may have had in doing the self-monitoring.
The therapist interprets any positive experiences in light of the program
rationale. For example,
THERAPIST: Mrs. B., would you share with the group some of your experiences
in doing the self-monitoring homework?
MRS. B.: I found it difficult to focus on the positive things I said to myself.
Thinking about how unhappy I have been was much easier. It seemed that I
have very few of the positive self-statements but more positive activities than I
expected.
THERAPIST: I suspect that many of the other group members had a similar experi-
ence. One of my efforts in the group will be to help you pay more attention to
the positive activities in your daily life and increase the frequency of the
positive things that you say to yourself.
During the review phase the therapist asks each person to read
examples from his or her list of positive self-statements and activities. If
a group member presents very few examples, the therapist will prompt
him or her to think of other kinds of positive self-statements or activities,
perhaps smaller or more trivial ones, that the person may have forgotten
to write down or dismissed as unimportant. The therapist encourages
group members to focus on the positive in their lives and this orientation
continues throughout the course of the group.
Mood and Behavior Exercise. The mood and behavior exercise is de-
signed to demonstrate, in a graphic form, the relationship between the
number and types of daily behavior (activities and self-statements) and
mood. It also provides several alternatives for understanding the rela-
tionship between mood and behavior.
THERAPIST: Now that we have a week's worth of information on your behavior
and your mood level, let's see if we can establish, in a more obvious form,
how the two are related.
78 MICHAEL W. O'HARA AND LYNN P. REHM
The purpose of this exercise is to look closely at the relationship between behavior
and mood. The assumption is that mood is influenced by behavior level generaUy or by
pecific types of self-statem nts and activity.
1. Mood and behavior graph: Using your self-monitoring log for the last week, graph
the number of po itive elf-statements and activities for each day u ing the scale at
the right. Now graph your week's mood using the scale at the left. Are the lines
roughly paraUel? Do the peaks and vaUeys correspond?
10 20
9 18
8 16
7 14
6 12 ..
-o
0
0
:E
5 10 ..
0
·:;;:
..::
q,
4 8 IXl
3 6
2 4
2
0 0
2. Pick out the 2 or 3 days on which your mood was the highe t. Figure out the
average number of po itive behaviors for tho days. Next, do the same for the 2
or 3 days on which your mood was the lowest. Is th average number of positive
self· tatements and activitie higher on the belt r mood days?
3. Look at your self-monitoring logs for the 2 or 3 days on which your mood was the
highest. What particular behavior happened on those days? Compare the logs to
the logs for your 2 or 3 worst mood days. What happened on the high mood days
that djd not happen on the low mood days?
4. Can you see a connection between your self-statements and activities and your
mood? People usuaUy find a connection betw en mood and either general
behavior level or orne specific type of behavior. One week's record may not
show thi relationship dearly but the program is based on the idea that mood can
be changed by changing self-statements and activities.
5. Repeat this exercise on next week's record .
FIG URE 2. Mood and behavior exercise.
Did most of you find that your mood level mirrored what you were
doing? Remember that there will not be a perfect one- to-one correspondence
between mood and the number of self-statements or activities since you may
on some days have a few very enjoyable events, and on others have many
events that are only moderately pleasurable. I want to emphasize that in the
long run the relationships between your self-statements and activities and
how you feel is quite clear. Your mood can be changed by paying more
attention to the positive and increasing the number of your positive activities.
Isolating Mood-Related Self-Statements and Activities. The mood and

behavior exercise served to underscore the general relationships be-
tween mood and behavior. The group members are asked to identify
specific self-statements or activities that have the greatest impact on
mood.
THERAPIST: Now that you see that your mood and behavior are related, let's try
to isolate the behaviors that have the greatest effect on your mood. Take a few
minutes right now to go back over the log sheets for the past week. Look at
those days when your mood was the best. Are there particular self-statements
or activities that stand out as responsible for better mood on those days? Are
there particular classes of behavior that are checked off more often on those
days? Do you have some idea already as to which self-statements or activities
do most for your mood?
Which of those positive behaviors that were infrequent do you feel would
make you feel good but right now occur at a very low frequency or not at all?
Group members are taught to become aware of effective self-state-

ments or activities that help to bring their mood up. The therapist en-
courages discussion among the clients as they explore which behaviors
help them to feel better.
Homework Assignment. Group members continue monitoring posi-
tive self-statements and activities as well as mood. The therapist asks
that they pay particular attention to those behaviors that seem most
influential in changing mood.
Session 3: Immediate versus Delayed Consequences

This session wraps up the self-monitoring module. The rationale for
the session is that depressed persons often focus on the immediate
"negative" consequences of an activity rather than delayed "positive"
ones. Immediate consequences are often "effortful behaviors" (e.g., get-
ting dressed and made up) and delayed consequences are often pleasant
experiences (e.g., being at a party with friends). Again, keeping with the
theme of the program the therapist attempts to instigate a change in
attentional set from the negative (difficult arduous task) to the positive
(pleasant delayed consequence).
Homework Review. Group members have continued to monitor their

positive self-statements and activities and have graphed them as well in
the same manner as in the previous session.
THERAPIST: A number of you found that your mood and behaviors seem to
parallel each other quite closely. Others have found a definite relationship
although not quite as strong. What you need to remember from this exercise is
that you have a clear demonstration that your moods are not mysterious or
uncontrollable. In fact, what you are doing and what you are saying to your-
self have great influence on how you feel. The rest of the therapy sessions will
build on this initial principle.
Group members are encouraged to discuss problems with their monitor-
ing during the past week. The therapist will prompt members to describe any
changes that they noticed in their mood due to the monitoring especially of
the targeted positive self-statements and activities. Again, the therapist tries
to help each group member identify classes of self-statements and activities
that are especially related to positive mood.
Rationale. The therapist stresses that depressed persons tend to

focus on negative rather than positive events in their lives and that their
self-statements usually have a negative cast. The negative focus is often
a distorted and unrealistic assessment of what is going on. Group mem-
bers are told that over the next several weeks they will learn new ways
to perceive events accurately and realistically and that this process will
have the effect of lessening their depression. The explicit rationale for
the current session is then developed and later extended in the session
exercise.
THERAPIST: Events often are defined as positive or negative in terms of their

consequences. For example, painting the house is negative because it is ex-
hausting and unpleasant. Eating an ice cream cone is negative because of self-
statements about gaining weight. Finishing a job is positive because it is over
and you can relax for a while. These consequences or self-statements about
them often make an event pleasant or unpleasant. Virtually all activities or
events have many consequences: some are negative and some are positive,
some are immediate and some are delayed. People who tend to be depressed
focus on the negative consequences and miss positive consequences, es-
pecially if they are delayed.
Immediate versus Delayed Effects Exercise. Group members are taken

through the example on the exercise worksheet. They discuss with the
therapist and among themselves the issues raised in the exercise. Em-
phasis is given to the identification of delayed positive consequences of
effortful behavior.
1. Choose four different activities that you recorded during the pa t week on your Self-
Monitoring Logs. Write them in on the pace at left on the worksheet.
2. For each activity fill in the effect in the four spaces to the right. Effects can be
payoffs or consequences of an activity, that is, the reason you do it, the meaning it
ha for you. Effects can be either positive or negative. Most activity has both po itive
and negative effects (reward and punishments, benefits and costs). Effects can also
be immediate or delayed. Most activity has an effect at the moment but also may
have a long-range cost or benefit. See the examples below.
3. Example:
Activity-
Immediate Delayed
(A) Ate an ice cream cone ~ Good taste Get more done
·.c nice break if take breaks
·~
0..
rested
"'
·.>c Expense Gain weight
~
z"'
(B) Called friend to come ~ enjoy talk Better friendship

over for coffee ·.c
·;;;
ci?.
~
·.c
S> Nervous about call Less work done
z
4. Which were easier to think of? Immediate or long-term effects? Positive or negative
effects? Which are you more likely to be aware of at the time you are doing
something? Did you think of effect that had not occurred to you before? Are there
instances where you might do things differently if you concentrate more on the
delayed than on the immediate effects or vice versa?
5. During the coming week, use the extra column on your self-monitoring log to fill in
a positive delayed effect of at least one positive activity per day.
FIG URE 3. Immediate versus delayed effects exercise.
(continued)
Worksheet
Effects
Activity Immediate Delayed
1. --------- ----------
2.
..
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..
z
~
3. ------------------ ..
·.>
:::
·~
c..
..
.::
~
2
4. ________________
..
·~
2
.."'
0()
5. _________________
.,
::
·~
;;;
0
..>
:c
.."'
z
0()
FIGURE 3. Continued
Homework Assignment. Group members continue to monitor posi-

tive self-statements and activities. In addition, they are requested to
identify a delayed positive consequence of at least one positive activity
each day and log it in the extra column of their self-monitoring log.
Session 4: Attribution of Causality

In this session the program changes its focus somewhat. The group
begins to address problems that depressed persons have in self-evalua-
tion. The attributional styles of depressed and nondepressed persons
are described and a strategy to counteract group members' tendency
toward dysfunctional attributions is elaborated.
Homework Review. The previous week's homework is reviewed and
problems with it are discussed. If group members have had a difficult
time identifying delayed positive consequences of daily activities, the
group is invited to collaborate to assist every participant in completing
her assignment.
Rationale. Dysfunctions in attributional style serve to maintain dys-
phoric mood for the depressed person. Self-statements about the causes
of positive and negative experiences are the direct target of intervention.
The therapist explains that the group will explore together examples of
how their attributions about causes of success and failure influence their
mood.
THERAPIST: People who are depressed tend to distort the nature of events and
make them negative by the way in which they attribute the causes of events.
Here are some examples:
1. After a minor quarrel with a friend, a woman feels depressed because
''I'm always making people mad at me."
2. A woman's work is praised by her boss and she says, "He's just trying to
make me feel better after the criticism he gave me the other day."
3. A friend in a hurry rushes by without stopping to say hello. The de-
pressed self-statement is "She doesn't like me any more."
4. A woman who has just gone back to school gets an A on her first exam.
She says, "The exam was just easy. I'll never do well on a hard one."
In each of the examples the woman involved made an attribution that made
positive outcomes negative and negative ones worse.
The therapist goes on to explain the way in which depressed per-

sons make attributions about the causes of success and failure (positive
and negative events). Depressed persons view their successes as due to
external, unstable, and specific causes.
THERAPIST: External causes are ones such as someone else or luck (for example,
"Oh, I was just lucky"). An unstable attribution means that you believe that
the cause may not be present in the future ("Just because I did well this time
doesn't mean I'll do well next time"). A specific attribution for success refers
to your belief that the cause of the success was unrelated to anything else
going on in your life ("Doing well on this doesn't mean I'll do well on that").
As children we are taught to make these external, specific, unstable attribu-
tions about success. It is the "modest" thing to say, whether or not it is true.
Nondepressed attributions about successes are usually (1) internal,
(2) general, and (3) stable. For example, 'I did a good job, didn't I?' 'I can do a
lot of things well when I try' and 'I'm confident in my ability to do this.' These
are all 'immodest' self-statements, but when true, they contribute to a sense of
control over your life, to positive self-esteem, and lessen depression. What I
am talking about is not bragging. It is important for you to recognize your
skills, abilities, effort, and accomplishments. The majority of the successes
you experience are things that you plan and work for and you deserve credit.
Self-Statements About Success Exercise. The purpose of the exercise is

to help group members take credit for successes. The therapist should
actively assist group members in assigning percentages to the three
dimensions of causality and developing positive self-statements.
Self-Statements About Failure Rationale and Exercise. Depressed per-
sons also show a pattern of self-statements characterized by internal,
general, and stable attributions for failure.
THERAPIST: Statements like "It was my fault" or "I let him down" are typical
internal statements about failure. People who are depressed tend to accept
guilt and responsibility for negative events. "I can't win whatever I do" or "I
can't do anything right" reflect general attributions about failure. People who
are depressed also tend to overgeneralize about negative events. Statements
such as ''I'll never get this right" or "This always happens to me!" are reflec-
tions of another depressive tendency, to see negative events as constant and
inevitable.
The therapist emphasizes that these types of attributions regarding

failure are learned at an early age and often prevent individuals from
attempting change. They are told that if a problem is due to a general
and stable aspect of themselves, there is nothing they can do about it. If
the cause is external, specific, or unstable, there is more likelihood that
they can do something. Group members complete the remainder of the
attribution exercise for negative events.
tive self-statements and activities. In addition, members are asked to log
The purpose of the exercise is to help you make realistic self-statements about your
successe and failures.
I. List two positive events that may have occurred for you in the past week. They
need not be major events; many trivial occurrences can be considered successes.
EventA: -----------------------------------------------------
EventB: ______________________________________________________
2. ow rate each event as to whether its causes were (1) internal or external, (2)
general or specific, and (3) stable or unstable. If you were completely responsible,
you would rate 100%. If you shared some responsibility with other factors, you
might rate near 50%. And if you were not at all responsible, you would rate 0%.
Rate the degree to which the cause of the event was general or specific. If it wa
caused by something that determines many things that happen to you. rate the
event 100% general. If it was something that only influences some things, use a
figure around 50%. lf it was an unusual, specific cause, rate at or near 0%.
Rate the degree to which the event was cau ed by something that is stable or
unstable. Rate it stable if the cause was something that will be constant or
persistent and affect other things in the future. Rate it around 50% if it may or
may not operate in the future. Rate it 0% if it was a unique ~ause unlikely to occur
again.
Event A: _____ % internal _ _ % general _ _% stable
Event B: % internal _ _% general _ _% stable
3. Now write a po itive self- tatement about each event that reflects its cause or
causes. These statements should be positive a11d true, that i , realistic and
accurate. Note that most statements fit under more than one (u ually all three)
dimension of attribution, for example, "I was lucky" is external, specific, unstable.
EventA:-----------------------------------------------------
EventB: ______________________________________________________
4. Now list two unpleasant or negative events that may have occurred over the past
week.
EventA:-----------------------------------------------------
Event 6: ------------------------------------------------------
5. In the same way as for your positive events rate the degree to which the events
were internal, general, and stable.
Event A: % internal _____% general _ _% stable
Event B: ===%internal _ _% general _ _% stable
6. Now write a positive self-statement about each event that accurately reflects its
cause or cause . The events that you list will probably be attributable to others or
to chance. Those unpleasant events that are attributable to you may reveal targets
for change, an issue that we will address next week.
EventA: ------------------------------------------------------
EventB: __________________________________________________ _
FIGURE 4. Attribution of responsibility exercise.

at least one positive self-statement about one success (positive event)

and one failure (negative event) each day.
Session 5: Goal Setting

Two sessions devoted to goal setting conclude the self-evaluation
module. The program aims to remedy two common dysfunctions of
the depressed group member with the goal-setting intervention: the
stringent standards of performance that they set, and their difficulty in
mobilizing personal resources to accomplish important goals.
Homework Review. The important concepts from the session on at-
tribution are reviewed and difficulties with the homework are dis-
cussed. Group members often resist taking responsibility for success
and the therapist will explore with them their various reactions to the
homework. Group members who experienced positive outcomes with
the homework serve as useful models for those who had problems with
the assignment.
Rationale.
THERAPIST: People who are depressed tend to set unrealistically stringent goals
or standards for themselves. Depressed persons are often perfectionistic and
they set goals that are distant, abstract, overly general, and unobtainable.
Partial accomplishment of goals is not fulfilling and the result for the person is
a constant sense of failure. For example, a woman might feel depressed if she
were unable to complete all the work her boss had given her that day even if it
were an unreasonable amount. Our effort will be to help you to set goals that
are realistic.
Four criteria for realistic goal setting are discussed with the group
members. A general strategy for the selection of goals within the imme-
diate therapy context is to select a class of activities related to good mood
that may be occurring infrequently. A minor goal may be selected first
with more important serious goals being selected later. Goals should be:
(a) positive, increasing something in frequency or duration, not decreas-
ing or getting rid of something; (b) attainable, a goal should be within
group member's realistic possibilities, that is, something he or she actu-
ally could expect to occur; (c) in the individual's control, that is, some-
thing that is within the span of a group member's abilities and efforts. It
should not be something that depends on the whim of others.
Goals should be broken down into subgoals meeting the same crite-
ria as for goals with one addition. Subgoals should be operational. The
Goal: Broad or long range:

"I want to i n c r e a s e - - - - - - - - - - - - - - - - - - - - - -
St1bgoals:
1. - - - - - - - - - - - - - - - - - - - - - - - -
2. ----------------------------------------------
3. _____________________________________________
4. - - - - - - - - - - - - - - - - - - - - - - - - - - -
5. - - - - - - - - - - - - - - - - - - - - - - - - -
othe.~---------------------------
Assigwnent:
l. Establish goals and subgoals. The general idea is to break down the overall goal
into mall, individual teps. To begin with, you may have to generate a whole
list of possible steps and then select out of this list the best and mo t orderly
tep . Subgoals should be defined uch that they are (A) positive, (B) attainable,
(Q in your control, and (D) operational.
2. R vi or make up additional worksheet for the above or different targets (2 at
most for now).
3. Continue monitoring a in previou week all po itive activities.
4. If an activity falls within your goal category, make a check mark in the extra
column of your elf-monitoring log.
5. Try to increase goal-related activities.
FIGURE 5. Self-evaluation worksheet.
subgoal should be defined in terms that identify specifically what behav-

ior is to be performed in a way that would allow anyone to recognize
when it has been met. This will mean that criteria for successful comple-
tion are built in. Examples of goals that meet the above criteria are
discussed by the therapist.
Goal-Setting Exercise. The self-evaluation worksheet is completed by
group members as they develop their own goals and subgoals. The
therapist and the rest of the group provide feedback to each group
member regarding his or her goals so that the goals of all group mem-
bers meet the criteria that they had discussed.
Homework Assignment. The homework is to revise or make up addi-
tional goals meeting the criteria of being (a) positive, (b) attainable,
(c) in your control, and (d) for subgoals, operational. Self-monitoring
also continues with special reference to subgoal behavior.
Session 6: Goal Setting Continued

The rationale and strategy of effective goal setting are thoroughly
reviewed in this session. Goals and subgoals that group members have
developed are reviewed with the entire group.
Homework Review. Group members are asked individually to dis-
cuss their progress toward their goals and subgoals. They are encour-
aged to give feedback and support to each other, especially regarding
work on subgoals. The therapist also reviews material from the previous
week. Three points are emphasized: (1) depressed persons set criteria
for goal accomplishment that are too stringent (i.e., too high or too
broad); (2) they do not give themselves enough time to accomplish a
goal; or (3) they do not recognize when they have made progress toward
a goal.
Rationale and Exercise. Typically, group members have difficulty in
two areas in attempting to do the goal-setting homework. First, they
often select goals that are too problematic or large (e.g., finishing college
or saving my marriage). The second problem that often develops is a
subgoal that is too ambitious (e.g., contact 20 businesses a day where
the goal is to get a job). In the first case the group member is encouraged
to start with a smaller goal that is more likely to be attainable in the short
run or to scale the goal down somewhat. In the second case, the member
is encouraged to break down complex, difficult, or important subgoal
activities into smaller steps. Ocassionally, an insufficient number of sub-
goals are developed so that they do not readily lead to the achievement
of the overall goal. In this case, group members develop further sub-
goals.
tive self-statements and activities with special reference to goal-related
behaviors.
Session 7: Overt Self-Reinforcement

Up to this point in the program group members have learned to
monitor positive activities and self-statements, to make accurate attribu-
tions for success and failure, and to develop realistic goals and subgoals.
The self-reinforcement module is concerned with the maintenance of
difficult or arduous behaviors through the contingent application of
overt and covert self-rewards.
Homework Review. The therapist reviews with each of the group
members their progress on goals that they have set. In addition, sub-
goals are further broken down if need be to make them more managea-
ble.
Rationale. Group members are told that up to this point we have
focused on paying attention to and increasing positive self-statements
and activities. Mood responds positively to increases in these activities.
The therapist also discusses another class of events that is important in
overcoming depression.
THERAPIST: There is another class of events that also has a powerful effect on
mood, that is, engaging in activities that, though not pleasurable in and of
themselves, are either necessary or very desirable to accomplish. These are
the kinds of tasks that give you a sense of accomplishment or relief to finish.
They may be anything from household chores to school term papers to writ-
ing letters. They are often tasks that hang over you and that you think of
frequently with guilt or anxiety or some other negative statement to yourself
about your inability to get them done. These tasks, if swiftly finished, could
lead to a significantly improved mood level, since you could then see tangible
evidence of progress in problem areas. The focus of our next section will be to
help you to accomplish some of these difficult but important tasks as well as
subgoals that are difficult for you.
At this point the therapist explains some basic concepts about how
behavior is controlled by rewards and punishers. The point is made that
reward comes only after a desired behavior has occurred. People can
control their own behavior by giving themselves rewards and punish-
ers. These rewards may be overt (providing a tangible reward such as a
new dress) or covert (verbalizing to themselves a positive statement
such as "Boy, I really did a nice job"). Self-punishment is accomplished
in much the same way, although it is probably more often a self-state-
ment (e.g., "That was pretty dumb" or "I was a real idiot to have failed
at that task").
THERAPIST: People who are depressed tend to punish themselves too much and
reward themselves too little. They tend to be down on themselves and con-
sistently seem to punish their behavior. They will downgrade their own ac-
complishments (for example, the woman who says "This old thing?" or the
woman who does not reward herself for having done well in a course at
school but instead becomes angry with herself for not having done better on
the final exam). These same people find it difficult to reward themselves or to
feel that they are deserving of any kind of positive activity or event in their
life. The result is that they are not motivated to be more active in pursuing
their goals. The depressed woman is more likely to focus on what has not
been accomplished than on what has been done. This notion relates back to
what we have been stressing all along regarding self-monitoring. If you are
continually monitoring your failures and other shortcomings, it is not surpris-

ing that you frequently would get down on yourself in the form of self-
punishment. Of course, the more often you punish yourself the less likely it is
that you will do the things that are necessary to help you feel less depressed.
Under these circumstances it is easy to allow yourself to engage in only the
most basic and necessary activities. Often these activities are accomplished
only with great difficulty or in some cases, not at all. In the absence of rewards
for difficult tasks, there is little motivation to continue to do them.
Reward-Menu Exercise. Group members develop for themselves a

reward menu from which they will select rewards for increasing goal-
related behavior. On the reward menu group members should list as
many potential rewards as possible. The rewards should be (a) truly
enjoyable, (b) varying in magnitude from large to small, and (c) capable
of free administration. Activities as well as things can be rewards and
the self-monitoring logs may provide examples of both. The principle to
be used is that easy activities can be used to reward hard positive
activities.
THERAPIST: The idea of the "reward menu" is that each time you accomplish one
of your difficult subgoal activities, you should reward your progress toward
your goal with something from the "reward menu." You want to motivate
yourself to work on the difficult subgoals with the added incentive of the
reward. It may sound unnecessary or "improper" to do something nice for
yourself, but at the moment we are interested in producing change, that is, a
shift in your usual habitual pattern of behavior, and reward is one way to
facilitate change.

tive self-statements and activities. In addition, each time a difficult sub-
goal activity is accomplished, they reward it with a positive activity from
their reward menu. They are instructed to match the size of the reward
to the difficulty of the task that is accomplished.
Session 8: Covert Self-Reinforcement

The previous session focused on the application of overt reinforcers
to reward difficult behaviors. It often is impractical or inappropriate to
reinforce goal-directed behavior with concrete reinforcers. The use of
covert reinforcers (positive self-statements) is developed in this session
as a portable alternative.
Homework Review. The therapist reviews with each group member

his or her efforts to increase goal-related activities and the use of con-
tingent reward menus. Group members read examples of the subgoals
accomplished and the items they chose from their reward menus. If any
group member reports difficulty with the assignment, the therapist,
with input from the rest of the group, will troubleshoot.
Rationale. A review of the rationale from the previous session will
serve to prepare group members for the concept that changing their self-
statements may have a positive impact on their mood.
THERAPIST: This week I want to talk about rewarding and punishing self-state-
ments. Last week we talked about object or activity self-reward. This week we
will concentrate on verbal self-reward. People can and most often do reward
themselves with a positive thoughts or self-statements. Such self-statements
focus your attention on accomplishments, strengthen that behavior, and serve
as the basis for positive self-evaluation and self-esteem.
In order to overcome long-held biases most group members will

have against self-praise, the therapist will develop the following ration-
ale.
THERAPIST: Self-reward is not bragging or excessive pride. Bragging is trying to

elicit compliments (rewards) from others by publicizing your accomplish-
ments. Excessive pride is unrealistically overestimating your achievements
and ignoring your limitations. Self-reward is a realistic recognition of your
skills and efforts. It is the basis for self-esteem and it makes you partly inde-
pendent of the evaluations of others. It is always nice to be recognized or
complimented by others but it is essential to self-esteem to be able to recog-
nize and evaluate your own behavior.
Covert Self-Reward Exercise. Group members develop at least five

statements that are positive and true about themselves, that is, five
positive characteristics. For example, I am good at ... being a mother,
my job, cooking, or solving problems. Or I am ... friendly, sincere,
hardworking, or loyal. Again, prompting and exploration with each
member may be necessary to aid group members in developing at least
five positive self-statements.
Homework Assignment. In addition to self-monitoring, group mem-
bers are asked to include on their daily log at least two self-statements
that are self-rewards that contingently follow a subgoal that is successful
and/ or difficult. They also are encouraged to add to their log any addi-
tional positive characteristics during the week.
Sessions 9 and 10: Review and Consolidation

New material has been presented practically every week and the
last two sessions afford an opportunity for group members to consoli-
date their new learning. The therapist may find it useful to review with
the group its progress toward the goals that the members set for them-
selves.
It is important to emphasize that the group has learned skills that
may continue to be applied after the termination of therapy. Group
members may want to share with each other some of their strategies for
maintaining their gains from therapy. The therapist also may ask ques-
tions such as, "What areas may prove troublesome in maintaining free-
dom from depression?" It is important to emphasize that the increase in
their self-control skills is the key to prevention of future episodes of
depression or ameliorating those episodes before they become so se-
rious as to require professional help again.
CAsE ExAMPLE
The following case example illustrates the treatment course of one

client who is typical of those we have treated.
Mary S. was a 47-year-old mother of two children and was

moderately depressed (BDI = 28). One of her children was married
and had moved away; the other was a high school senior still living
at home. Mary had been a housewife most of the past 25 years,
occasionally working part time as well as frequently doing volunteer
work in the community.
When Mrs. S. was asked what she believed accounted for her
current depression, she said that she and her husband had not been
getting along for the last couple of years and that she was feeling
useless and bored. Mrs. S. never had been in therapy before, though
her private physician had frequently prescribed Valium for her anx-
iety and depression.
During the first session Mrs. S. was surprised to find other
women who were experiencing similar problems. The group also
evidenced support and understanding of her difficulties. The thera-
pist called her in the middle of the week to troubleshoot any prob-
lems and she reported that she had logged only a few positive self-
statements and activities. She was reminded to log all positive self-
statements and activities, particularly trivial ones, and at the thera-
pist's prompting she was able to recall several that she had not
logged.
In the second group she complained that even though logging
positive self-statements and activities did have some positive impact
on her mood, she could not see how that would help her with her
"real problems" of being bored and feeling useless and with her
difficulties with her husband. However, she was able to see on the
Mood and Behavior exercise that there were parallels and that she
could identify both self-statements and activities that were especially
related to positive mood.
Throughout the next several sessions the therapist continued to
prompt her to log the trivial self-statements and activities as well as
the more important ones. She had difficulty accepting the attribution
rationale, particularly taking credit (internal attribution) for positive
outcomes in her life. At this point she was still moderately de-
pressed (BDI = 25) and continued to need extra encouragement
from the other group members and the therapist.
During the goal-setting sessions, she learned to set realistic
goals for herself, particularly in the area of improving her relation-
ship with her husband and finding a part-time job. Earlier in the
group she complained that her relationship with her husband had
deteriorated and that there was nothing she could do about it. Her
subgoals were to arrange for them to engage in pleasurable activities
together and to increase the number of questions she asked him
about his work activities. Within a couple of weeks she reported that
her husband was much more responsive toward her and she took
credit for the change. By this time, her mood also was improving.
By the last three sessions, she felt committed to change and
used both material rewards and positive self-statements to reinforce
her job-finding efforts. By the end of the group her depression had
abated (BDI = 6) and she expressed satisfaction and surprise that
she could make such a difference in her own life.
REFERENCES
Beck, A. T., Ward, C. H., Mendelson, M., Mock, J., & Erbaugh, J. An inventory for
measuring depression. Archives of General Psychiatry, 1961, 4, 561-571.
Fuchs, C. Z., & Rehm, L. P. A self-control behavior therapy program for depression.
Journal of Consulting and Clinical Psychology, 1977, 45, 206-215.
Kanfer, F. H. Self-regulation: Research issues and speculations. In C. Neuringer & J. L.
Michael (Eds.), Behavior modification in clinical psychology. New York: Appleton-Cen-
tury-Crofts, 1970.
Kanfer, F. H. The maintenance of behavior by self-generated stimuli and reinforcement. In
94 MICHAEL W. O'HARA AND LYNN P. REHM
A. Jacobs & L. B. Sachs (Eds. ), The psychology of private events: Perspectives on covert
response systems. New York: Academic, 1971.
Kanfer, F. H., & Karoly, P. Self-control: A behavioristic excursion into the lion's den.
Behavior Therapy, 1972, 3, 398-416.
Lubin, B. Manual for the depression adjective check lists. San Diego: Educational and Industrial
Testing Service, 1967.
Rehm, L. P. A self-control model of depression. Behavior Therapy, 1977, 8, 787-804.
Rehm, L. P. A self-control therapy program for the treatment of depression. In J. F.
Clarkin & H. Glazer (Eds.), Depression: Behavioral and directive treatment strategies. New
York: Garland, 1981.
Rehm, L. P., Fuchs, C.Z., Roth, D., Kornblith, S. J., & Romano, J. M. A comparison of
self-control and assertion skills treatments for depression. Behavior Therapy, 1979, 10,
429-442.
Rehm, L. P., Kornblith, S. J., O'Hara, M. W., Lamparski, D. M., Romano, J. M., & Volkin,
]. An evaluation of the major elements in a self-control therapy program for depres-
sion. Behavior Modification, 1981, 5, 459-489.
Romano, J. M., & Rehm, L. P. Self-control treatment of depression: One year follow-up. In
A. T. Beck (Chairperson), Factors affecting the outcome and maintenances of cr>gnitive
therapy. Symposium at the meeting of the Eastern Psychological As3ociation, Phila-
delphia, April 18-21, 1979.
Spitzer, R. L., Endicott, J., & Robins, E. Research diagnostic criteria: Rationale and reliabi-
lity. Archives of General Psychiatry, 1978, 36, 773-782.
5
Cognitive Therapy in the
Family System
RICHARD C. BEDROSIAN
COGNITIVE THERAPY IN THE FAMILY SYSTEM
Cognitive therapists generally treat patients in individual or group ses-

sions, but rarely work with marital or family units. An underlying prem-
ise of individual therapy is that the problem resides within the psyche of
the particular patient and that recovery can occur to the extent that his or
her cognitive distortions change in the course of treatment. For many
patients, the premise is at least partially valid in that they experience
symptom relief as a result of individual sessions with a therapist. In
other cases, however, the cognitive therapist will find it necessary to
modify both cognitions and relationships by including other family
members in the treatment process (Bedrosian, 1981).
The' Relationship between Individual Symptoms and Family

Interaction Patterns
The most radical family systems position views all or most man-
ifestations of individual psychopathology as reflective of dysfunctional
family interaction patterns. At best, the research literature offers mini-
mal support for such a viewpoint (Jacob, 1975). A more conservative
position, which acknowledges the process of reciprocal influence be-
tween the individual patient and significant others in the environment,
is detailed in the following propositions.
RICHARD C. BEDROSIAI'-: • Massachusetts Center for Cognitive Therapy, Westborough,

Massachusetts 01581.
95
96 RICHARD C. BEDROSIAN
Proposition 1: Family systems can reorganize quickly in response to

individual psychopathology.
Imagine how the day-to-day management of your household would
change if your spouse became severely depressed or agoraphobic for
even a month of two. You would begin to assume many of your spouse's
chores and responsibilities. As time progressed, the role of your spouse
in major household decisions would tend to diminish. The added bur-
dens would create stress for you, but you also would become accustomed
to running the family in your own way. Eventually you would face the
difficult choice of curtailing your social life and any other activities you
enjoyed outside the home or risk isolating your spouse further. As you
withdrew from your network of friends and extrafamilial interests, you
would struggle with feelings of resentment toward your spouse.
The preceding actually represents a benign version of the family
situations that emerge in clinical practice. Loved ones repeatedly dem-
onstrate a willingness to accommodate to the most troublesome, inca-
pacitating individual symptoms. Consequently, what may begin as an
individual problem ends up as a way of life for an entire family. The
more chronic the symptom, the greater the disruption in the household.
Proposition 2: Good intentions notwithstanding, the family organiza-

tion that accompanies individual psychopathology may not support im-
proved adjustment on the part of the identified patient.
Family members often unwittingly help to maintain passivity and
avoidance behavior. The mother of a depressed, highly anxious yourtg
man would serve her son meals in his room, where he sat watching
television all day, despite the fact that the rest of the family ate together
in the dining room. If his friends called or came to the house, she obeyed
his request to tell them he was out. Rather than encourage her son to use
the self-control techniques his therapist had suggested to him, the moth-
er would dispense narcotics to him from her own supply of medication
whenever he found it difficult to cope with his anxiety.
Proposition 3: Ongoing family interactions can exacerbate symptoms

and trigger or intensify maladaptive cognitions.
Examples in which family conflicts aggravate individual symptoms
are numerous in clinical practice. Some depressed patients, for instance,
are prone to blame themselves for any problems in the family that may
occur. On the other hand, interacting with depressed individuals can
exert a noxious influence on others, as research has indicated (Coyne,
1976).
The manner in which interpersonal processes influence belief sys-
COGNITIVE THERAPY IN THE FAMILY SYSTEM 97
terns has been (and probably will continue to be) a source of controversy
among social psychologists. Nonetheless, we can assume that an indi-
vidual will retain a profound sense of hopelessness or a decidedly nega-
tive self-image if these attitudes constantly are being reinforced either
implicitly or explicitly by family members.
On the other hand, a process that resembles "psychological reac-
tance" (Brehm, 1966), seems to occur in the families of some clinic pa-
tients. Brehm postulates that when an individual is faced with elimina-
tion or threatened elimination of behaviors he or she originally felt free
to perform, a motivational state, labeled psychological reactance, is
aroused. The theory predicts that when an individual feels free to reject
or adopt any of a number of attitudinal positions, pressure to adopt or
reject any one position threatens that freedom, thereby arousing reac-
tance and leading to efforts to restore the freedom by resisting persua-
sion or adopting a position at variance with the one recommended (Hass
& Linder, 1972).
As observed among clinic families, psychological reactance occurs
when the identified patient clings all the more tenaciously to a dysfunc-
tional belief system in response to persuasion or pressure from family
members. A woman viewed isolated incidents as proof that she was
performing poorly at her job and ruminated constantly about being
fired. The hours she spent at home discussing her job worries put a
severe strain on her marital relationship. Her husband would attempt to
talk her out of her beliefs in a pedantic, condescending manner. When
he became exasperated with his wife, he would simply attack her ideas
as "stupid." The more her husband attacked her, the more the woman
defended her beliefs, as well as her right to hold them. At one point she
protested, "What do you know about my job? You're on easy street
where you work!" It was necessary to modify the interactional pattern
that produced the husband's aversive comments and the wife's right-
eous indignation, before the therapist could focus on the anxiety over
work.
Proposition 4: Improvement on the part of the identified patient can
produce an increase in stress for other family members.
Imagine again that you have reorganized your household in re-
sponse to your spouse's emotional problems. As your partner recovers
from his or her difficulties, the two of you will find it necessary to
renegotiate the distribution of power and responsibility in the house-
hold. Suddenly you find that you cannot make major decisions uni-
laterally without antagonizing your spouse. Temporarily at least, even
the most routine family matters may require debate and discussion.
At times, treatment can lead to greater assertiveness on the part of
the identified patient, as well as other forms of behavior that can be

troublesome for family members. In order to preserve his health, a mid-
dle-aged cardiac patient began to curtail his business activities, since he
recognized that his attitudes toward work had contributed to his heart
problems. He allowed himself more leisure time and planned several
lengthy vacations with his family. As he spent more time at home with
his wife and his adolescent daughters, tensions rose sharply in the
household. Accustomed to occupying a position of leadership in the
business world, the man behaved in a bossy, intrusive manner at home,
which rapidly alienated the rest of the family.
Proposition 5: Individuals in family systems often behave on the
basis of assumptions about one another that may have little or no basis
in reality.
Married couples and other individuals who are in close contact
engage frequently in "mind reading," in that they anticipate one an-
other's tastes, attitudes, and moods in advance, without ever validating
their hypotheses. When "mind reading" is accurate, it tends to save time
and effort for the members of a family system. Unfortunately, when an
individual becomes depressed or anxious, cognitive distortions tend to
interfere with his or her ability to make inferences about the motives or
reactions of others, particularly in the absence of direct feedback.
Spouses who experience marital distress are likely to do a poor job of
communicating on an explicit level, so they fall back too often on dys-
functional assumptions in order to make predictions about their part-
ner's internal states.
A woman in her twenties who experienced symptoms of depression
and anxiety, complained about daily phone calls and visits from her
aged father-in-law. The man behaved in a rude, critical fashion during
his visits and often impeded her work in the home. Since she had
assumed that her husband knew and approved of the visits, she felt
powerless to alter the situation. During subsequent marital sessions, she
overcame her reluctance to raise the matter with her husband. She
found that he was unaware of the frequency and noxiousness of his
father's visits, and that he was supportive of her efforts to set greater
limits on the man's behavior.
GUIDELINES FOR ESTABLISHING CONTACT WITH SIGNIFICANT

OTHERS
1. The therapist should interview the spouse or other relevant fami-

ly members as early as possible in the course of treatment. Early contact
COGNITIVE THERAPY IN THE fAMILY SYSTEM 99
with significant others provides the therapist with a broader data base.
The identified patient's account of the family situation, which may be
the product of his or her cognitive distortions, can mislead the therapist,
particularly in the absence of information from other observers. Even
when they do not participate in subsequent treatment, family members
can use the interview to become acquainted with therapy and the thera-
pist. If they meet the therapist early on, significant others are more likely
to cooperate if he or she requests their presence during a later stage in
treatment.
2. As Haley (1976) recommends, early contacts with family mem-
bers should concentrate on the presenting problems of the identified
patient. In the early interviews, the therapist avoids tinkering with the
marriage or other relationships in the family unless he or she has made
an explicit contract to do so with the parties involved. The initial family
interview can be aimed at assessing the impact of the presenting prob-
lem upon the relevant family members, their reactions to the patient's
difficulties, and any solutions that they attempted to implement. The
therapist should avoid implying in any way that the family is to blame
for the patient's complaints.
3. Whenever possible, the therapist should speak directly to the
relevant family member(s) about attending a session. Delegating such a
task to the identified patient, which is generally the path of least re-
sistance for the therapist, can yield confusing results. If the family mem-
ber comes in for an interview, the therapist does not know what stimu-
lated the appearance unless he or she actually made the request.
Perhaps the identified patient has said, "My therapist wants to meet the
person who's driving me crazy," or "The doctor thinks you're sicker
than I am, so he wants to talk to you." If the family member fails to come
in, the therapist also will not know why. Some patients will speak to
their families about entering treatment in an unassertive or otherwise
inappropriate manner; others simply will fail to raise the issue at all,
only to tell the therapist that the family members are unwilling or unable
to participate. Clinical experience indicates that the majority of family
members will respond favorably to the therapist's request for their in-
volvement in the treatment.
MODIFYING INTERACTION PATTERNS THAT AGGRAVATE

CoGNITIVE DISTORTIONS
An unemployed college graduate in his early twenties sought treat-

ment for severe bouts of depression and anxiety. He complained of a
wide range of symptoms, including low self-esteem, social isolation,
and impotence. Through the standard cognitive therapy techniques, he

was able to curb his anxiety attacks and improve his morale. As his
depression began to lift he established a sexual relationship with a wom-
an 20 years his senior, much to the dismay of his parents. The woman's
behavior tended to support the parents' objections. She repeatedly ma-
nipulated the young man by capriciously terminating the relationship,
only to resume it again at a moment's notice. His moods alternated
between elation and despair, depending upon the status of the relation-
ship. The patient realized that it would be better for him in the long run
to sever the relationship, but held a number of dysfunctional beliefs,
such as "No other woman would want me" and "I hunger for love,"
which prevented him from taking decisive action.
The young man lived with his parents, who supported him finan-
cially and paid for his treatment. His relationship with the older woman
became the object of constant family conflict. Although their arguments
were quite sound, the more his parents attacked the relationship, the
more the son would defend his right to maintain it. He began reaching
out spontaneously to other women, but retreated quickly when his par-
ents began pressuring him to date others. Rather than pursue his evi-
dent interest in other women, he responded to the pressure from his
parents by reaffirming the dysfunctional belief, "There's only one wom-
an I can ever love." As the parents stepped up their efforts to influence
their son, they broadened their criticisms to include attacks on his worth
as a person. In addition to intensifying his depressogenic cognitions, the
family quarrels distracted the young man from his own concerns about
the relationship and diverted him from other important issues in his life,
such as job hunting.
After the parents had threatened to stop paying for treatment un-
less the relationship ended, the therapist invited both the father and son
in for a session. In a private meeting with the father, the therapist asked
the man to describe the worst that could happen to his son if the rela-
tionship were to continue. Would he have children with her? No. Marry
her? No. According to the father, his worst fear was that his son could
lose valuable time by remaining in the relationship. The man recognized
that neither he nor his wife were able to influence their son at all on the
issue. In fact, the father admitted that by pressuring his son he actually
made it more difficult for the young man to evaluate the relationship on
its own merits. Moreover, he expressed the belief that given time, the
son inevitably would break off the relationship. The father agreed that
by attempting to coerce the son, the parents actually were causing him
to lose time, which was just what they had feared to begin with.
The therapist met with the father and son together, and asked them
CoCNITIVE THERAPY IN THE FAMILY SYSTEM 101
to avoid any further discussion of the relationship. He suggested that

the young man try to discuss only vocational issues with his father, who
was highly qualified to serve as a resource on the subject. The pair
talked about job hunting during the remainder of the session, while the
therapist helped to divert them away from any further comments about
their disagreements. A similar meeting with the father and son occurred
a week later. Once again, the therapist encouraged the two of them to
focus on employment issues and intervened when the conversation
drifted back to the son's social life.
Since the family was able to avoid serious conflict over the son's
relationship, friction in the household began to subside. The parents
then were able to support their son in his attempts to resolve other
significant problems in his life. After considerable internal debate and a
few false starts, the young man subsequently broke off the relationship
of his own accord and began to date other women again.
TESTING AND MODIFYING ASSUMPTIONS ABOUT

RELATIONSHIPS
In individual treatment, the cognitive therapist often encourages

the patient to test actively the validity of his or her assumptions concern-
ing significant others. When a particular relationship seems to be a focal
point for the patient's distress, the process of "reality testing" can be
accelerated if the therapist includes the relevant individual(s) in the
session.
As discussed earlier, all of us conduct our social relationships on the
basis of innumerable inferences and assumptions that have varying lev-
els of accuracy. Clinical experience indicates that three types of cogni-
tions about relationships may require therapeutic attention:
1. Inferences about the Internal States of Others. Inferences of this sort
can focus on emotions ("I know you're angry because you're biting your
nails"), motivation ("You came home late because you knew my mother
was here"), attributional processes ("You'll think I'm to blame if we
don't enjoy our vacation"), and so on. To make matters even more
complicated, partners in intimate relationships often attempt to infer one
another's inferences, for example, "You think that I think you're stupid,
but it's not true." Individuals can become highly abstract and con-
voluted in their assumptions about one another's internal processes, as
illustrated by Laing (1961) and by Ralph Cramden of "The Honey-
mooners" ("You know that I know that you know that I know what's
going on").
It would appear to be a simple matter for a person to test out his or

her assumptions about the inner experiences of a significant other. In
fact, the process can be quite involved, particularly if the relevant indi-
viduals are unwilling or unable to self-disclose. Moreover, some persons
can maintain considerable leverage in a relationship simply by creating a
state of ambiguity regarding their feelings toward their spouses.
2. Expectations of the Other. We all possess a multitude of implicit
and explicit expectations regarding our partners in intimate relation-
ships. The content of such expectations can be highly idiosyncratic.
Some examples include: "I thought that when you changed jobs you'd
be spending more time at home" or "I want you to stay away from me
when I'm tired" or "I want you to accept my family as they are;" and so
on. As Lederer and Jackson (1968) point out, every intimate relationship
involves the establishment of a quid pro quo, which means, literally,
something for something. Unfortunately, when partners interact with
one another on the basis of implicit expectations or "unspoken conve-
nants" (Sager, 1978) the potential for dissatisfaction increases. Some
spouses often assume that their partners know what their unstated ex-
pectations are. When an unspoken demand goes unfulfilled, the spouse
may react as if his or her partner had refused to comply with a direct,
unambiguous request. For example, after working late, a psychologist
missed his commuter train. When he called his wife to inform her of the
delay in his return from work, he made it a point to mention that after a
long day at the office, he would now have to wait an hour until the next
train arrived. In the past, a similar line of conversation generally led to
his wife "spontaneously" offering to drive him home, but on this occa-
sion she merely offered her condolences and hung up. While waiting in
the train station, the psychologist began to ruminate about how nonsup-
portive, noncaring, and nongiving his wife was, and thereby managed
to arrive home in a surly, belligerent state. Only after a period of bicker-
ing did he recognize the connection between his present emotional state
and his clumsy attempt to provoke his wife's sympathy earlier. A major
goal in cognitive therapy with couples or families is to encourage the
participants to make all their demands and expectations of one another
as explicit and concrete as possible. The therapist adopts the stance that
only through making direct requests of one another can individuals
learn (1) if their demands are realistic or appropriate and (2) if the signif-
icant other(s) will comply. Note that in the example in the preceding
paragraph the psychologist made his request in an indirect manner
which precluded the possibility of feedback.
3. Rules about Relationships. In addition to rather specific expecta-
tions, individuals also hold generalized assumptions about the nature of
COGNlTIVE THERAPY IN THE FAMILY SYSTEM 103
their relationships with other family members. Such assumptions, like

other dysfunctional cognitions, can lead to inappropriate emotional re-
actions and a lack of behavioral flexibility. For example, the individual
who believes that people in love automatically should sense one an-
other's needs will find it difficult to communicate his or her demands
directly to loved ones. Some relationship rules reflect aU-or-nothing
thinking, for example, "If you love someone, you never get angry with
him" or "A wife always stands by her husband, whether he's right or
wrong." Relationship rules that reflect the individual's familial or sub-
cultural background, particularly those concerning the nature of male
and female roles, may be at variance with the current social context of
the family. As with other dysfunctional cognitions, the therapist strives
to make the individual's rules about relationship explicit, so that he or
she can examine their validity and/or utility.
The following case example illustrates how conjoint family or mari-
tal sessions can be used to correct cognitive distortions and faulty rela-
tionship patterns. A depressed business executive sought individual
treatment for chornic symptoms of anxiety and depression that originat-
ed primarily in the work setting. At first, the therapist worked with him
individually in order to modify the man's perfectionism and self-deni-
gration. As the work situation began to improve, the patient reiterated
the concerns about his marriage that the therapist had deferred earlier in
treatment. Characteristically, he blamed himself fully for the difficulties
that he perceived in the marital relationship. On the other hand, he
portrayed his wife as blameless, devoted to him, and perfectly content
with their life together.
If the therapist had continued to see the patient individually, he
eventually might have accepted the man's account of the domestic situa-
tion at face value and gone on to help the executive weigh the advan-
tages and disadvantages of a trial separation. Instead the therapist called
the wife and arranged a meeting with the couple. During the first con-
joint session, the wife seemed glib, sarcastic, and hardly contented with
the marriage. While meeting alone with the therapist, she said of her
husband at one point, "I've been protecting him all his life."
The therapist's first task was to redefine the marital dissatisfaction
of the husband as a relationship problem rather than an individual prob-
lem. To accomplish such a goal, the therapist had to help the executive
stop attributing the marital problems solely to himself. The therapist
encouraged the wife to explain to her husband exactly how she felt about
the marriage in a way that reflected the intensity of her own dissatisfac-
tion and disappointment. Gradually the husband began to view the
marital difficulties as a shared problem.
The therapist observed that although each spouse indicated dissat-

isfaction with the marriage, neither partner made many direct requests
for behavioral changes from the other. Neither partner seemed to lack
assertiveness in other social or work relationships. In the marriage,
however, both spouses maintained a detached, unassertive position.
Consequently, the therapist began to explore the spouse's dysfunctional
cognitions, using their requests and demands as the starting point. He
found that each partner held a number of beliefs that prevented direct
communication in the relationship.
The husband believed that his wife should be more "exciting and
spontaneous," that she somehow should be able to satisfy all his needs
instinctively, without any prompting on his part. Gradually, he realized
that his expectation for "spontaneous" behavior from his wife was both
unrealistic and unproductive. In fact, both partners cited instances in
which he had failed to respond to spur-of-the-moment suggestions
(e.g., "Let's go out dancing tonight") from his wife. Another dysfunc-
tional assumption that surfaced repeatedly on the husband's part was
the idea that if his wife complied with one of his requests he would be
obligated to her thereafter. Thus, if his wife responded to a desire on his
part for sexual relations, he would think, "She really doesn't want to do
this for me and she'll think I owe her." Nonetheless, his wife seemed
quite candid in her feedback whenever she found his requests unaccep-
table.
Dysfunctional cognitions also interfered with the wife's ability to
ask her husband for what she wanted. Because her husband had suf-
fered depressive symptoms, she believed that he might experience addi-
tional psychological problems if she pushed him to satisfy her needs. If
she expressed her wishes, by attempting to initiate sex for example, the
wife would distort the meaning of any negative response from her hus-
band. If her husband turned down her request for lovemaking she
would think, "He probably doesn't want me anymore" or "Now it's up
to him to make the first move, because I won't ask him for anything
now." The wife selectively attended to instances of coldness or rejection
on the part of her spouse, while overlooking situations in which he had
been warm and attentive to her needs.
Session after session, the therapist pursued the same strategy with
the couple. He would urge one of the spouses to make explicit, concrete
requests of the other. The requests had to involve observable behaviors,
rather than attitudes. Thus, "I want you to come to realtor's on Sunday"
was acceptable; "I want you to show an interest in house hunting" was
not. Once they began making appropriate requests, the spouses then
were able to test out their dysfunctional assumptions about the relation-
COGNITIVE THERAPY IN TilE FAMILY SYSTEM 105
ship and one another. The husband quickly realized that his demands
for "spontaneous" behavior from his wife created a situation in which
compliance was impossible. As therapy continued, he grew less dis-
trustful of his wife's reactions to him. He found that she truly enjoyed
doing things simply to please him. The wife, on the other hand, dis-
covered that her husband could tolerate a good deal more pressure from
her than she had anticipated. Indeed, by behaving more assertively, she
actually began to provide her husband with the sense of spontaneity
and excitement that he had wanted. With practice, she began to resist
her tendency to overreact when he refused her requests. With the thera-
pist's help, the couple communicated more effectively and directly on a
number of issues, such as sexual relations, childrearing, and social in-
teractions, which they had avoided due to prior disagreements.
COPING WITH STRESSES INDUCED BY POSITIVE TREATMENT

EFFECTS
It is desirable to prepare family members for new stresses that may

arise as a result of symptom reduction in the identified patient. Such
stresses may necessitate a shift in the focus of therapy from individual to
relationship issues. In forewarning the family, the therapist can explain
that the new tensions within the household are not catastrophic, and
can be alleviated in the course of treatment.
A married woman in her late twenties experienced a rapid onset of
severe agoraphobic symptoms as she recovered from a long-standing
depression. It is noteworthy that her agoraphobia began just after she
and her husband made their. annual move to the resort town where he
ran a seasonal business. While the husband worked extremely long
hours in the business, the wife experienced boredom and social isola-
tion. Nonetheless, the husband was very helpful and considerate to his
wife during her most symptomatic period, when she was unable to
drive or enter public places alone.
The therapist believed that the patient's problems were closely re-
lated to unarticulated grievances within the marital relationship. Both
spouses denied the presence of any marital difficulties, but the therapist
warned them that conflicts at home might occur once the wife no longer
occupied such a helpless position.
Through a combination of group and individual cognitive therapy,
the woman learned to control her anxiety symptoms. As she improved,
conflicts did in fact emerge in the marriage. The major issues were the
husband's summer business, which the patient felt constrained their
life-style unnecessarily, and his parents, whom the patient perceived as

intrusive and domineering. It was clear that the spouses held widely
divergent attitudes about male-female relationships, stemming in part
from the differences in their backgrounds.
Once her symptoms diminished, the woman was urged to be more
assertive in her marriage. She began to acknowledge, grudgingly at first,
the effects of her marriage upon her symptoms. As his wife began to
demand equal time for her needs, the husband became more irritable
and withdrawn, uncharacteristically so for him. Through the use of
conjoint sessions, however, the couple achieved a more equitable bal-
ance of power and rewards in their relationship.
CoNcLUSION
The present chapter explored the interface between cognitive thera-

py and family therapy. The author's experiences to date indicate that the
two approaches blend readily with one another. The territory of "cogni-
tive family therapy" remains largely uncharted, so that innumerable
adventures and mysteries await future explorers there.
REFERENCES
Bedrosian, R. C. Ecological factors in cognitive therapy: The use of significant others. In G.

Emery, S. Hollon, & R. Bedrosian (Eds.), New directions in cognitive therapy. New York:
Guilford, 1981.
Brehm, J. W. A theory of psychological reactance. New York: Academic, 1966.
Coyne, J. C. Toward an interactional description of depression. Archives of General Psychia-
try, 1976, 39, 29-40.
Haley, J. Problem solving therapy. San Francisco: Jossey-Bass, 1976.
Hass, R. G., & Linder, D. E. Counterarguement availability and the effects of message
structure on persuasion, Journal of Personality and Social Psychology, 1972, 23, 219-233.
Jacob, T. Family interaction in disturbed and normal families: A methodological and sub-
stantive review. Psychological Bulletin, 1975, 82, 33-65.
Laing, R. D. Self and others. London: Tavistock, 1961.
Lederer, W. J., & Jackson, D. D. Mirages of marriage. New York: Norton, 1968.
Sager, C. J. Marriage contracts and couple therapy. New York: Brunner/Mazel, 1978.
6
Couples
NoRMAN EPSTEIN
Although behavior th-erapists who treat distressed marriages tradi-

tionally have acknowledged that spouses' cognitive appraisals of each
other's behavior play a role in relationship dysfunction, interventions
focusing on cognitive components of relationship problems clearly have
played a secondary or even a minor role in formal behavioral ap-
proaches. However, due to the influence of a general growth of interest
in cognitive variables in behavioral models and to the recognition that
spouses' negative beliefs and attitudes easily can undermine even the
best conceived behavior-change programs (Jacobson & Margolin, 1979),
significant attention now is being paid to the development of assess-
ment and treatment procedures for cognitive factors. In the general
cognitive model, an individual's emotional and behavioral responses to
a stimulus (internal or external) are mediated by his or her perception
and interpretation of the stimulus rather than elicited directly by objec-
tive characteristics of the stimulus (Beck, 1976; Meichenbaum, 1977). In
an interpersonal system such as a marriage, the members of the relation-
ship continuously provide stimuli for each other and actively construe
the behaviors they exchange. Because marital satisfaction is a subjective
state that is related to proportions of idiosyncratically defined pleasing
and displeasing behaviors exchanged by spouses (Jacobson & Margolin,
This chapter is from "Cognitive Therapy with Couples" by Norman Epstein, The
American Journal of Family Therapy, 1982, 10, 5-16. Copyright 1982 by Brunner/Mazel, Inc.
Reprinted by permission.
NoRMAN EPSTEIN • Center for Cognitive Therapy, 133 South 36th Street, University of
Pennsylvania, Philadelphia, Pennsylvania 19104.
107
108 NORMAN EPSTEIN
1979; Weiss, 1978), understanding and changing a distressed relation-

ship necessitates attention to cognitive events in the marriage.
This chapter examines three major approaches to cognitive therapy
for marital problems: modification of unrealistic expectations of relation-
ships, correction of faulty attributions in marital interaction, and use of
self-instructional procedures to decrease destructive interaction. Means
for integrating cognitive and behavioral approaches to marital therapy
are described, and the extent to which cognitive approaches are con-
sistent with a systems view of marriage and marital therapy is dis-
cussed.
APPROACHES TO COGNITIVE THERAPY WITH COUPLES
The three forms of cognitive therapy described below traditionally

have been used to treat the problematic behavioral (e.g., impulsivity)
and emotional (e.g., depression) responses of individuals. However,
these cognitive approaches offer means of intervening in a dysfunctional
marital system where spouses' subjective distress and their exchanges of
negative behaviors are linked. In the discussion that follows, ways in
which cognitive interventions can be used both to alter subjective dis-
tress and to control expression of destructive behaviors in dyads will be
stressed.
Modifying Unrealistic Expectations

The expectations that each member of a couple brings to the mar-
riage regarding the nature of an intimate relationship and the roles of its
members are important foci of cognitive interventions with distressed
couples Oacobson & Margolin, 1979; O'Leary & Turkewitz, 1978). The
impetus for treatment of unrealistic or exaggerated expectations has
been Ellis's view (Ellis & Harper, 1975) that disturbed marriages result
when one or both spouses hold irrational beliefs (e.g., other's approval
is necessary; one must get one's way).l Ellis suggests that these unrealis-
tic, demanding expectations inevitably produce disappointment and
frustration, with associated negative emotions such as anger, and coun-
terproductive behaviors such as nagging. His rational-emotive therapy
(RET) is intended to challenge the validity of these irrational beliefs
1Inthe present chapter, the practice in the literature of using the terms irrational belief and
unrealistic expectation interchangeably to describe extreme or distorted standards that a
person applies to self, partner, or relationship will be followed.
CoGNITIVE THERAPY WITH CouPLES 109
directly. Distressed spouses are taught that particular expectations pro-

duce disturbed emotions and behavior, and they are coached in sub-
stituting more realistic thinking about themselves and their partners.
For example, it is stressed that blaming one's partner for his or her
mistakes only elicits counterproductive defensiveness, that it is human
to make mistakes, and that the important point is learning from one's
mistakes.
Ellis's approach to marital dysfunction tends not to be an interactive
systems view but an extension of his model of individual psychopathol-
ogy. However, it is likely that spouses reared in the same society will
share and reinforce each other's unrealistic expectations. Conjoint treat-
ment can be quite useful for identifying and challenging mutually held
dysfunctional expectations. Second, partners may have complementary
irrational beliefs, as when one spouse believes he or she must get his or
her way and the other believes that he or she must perform perfectly.
Such a couple may enact a destructive spiral in which the former nags
and the latter defends or withdraws in frustration. Also, it is important
to assess whether one spouse may in fact elicit and reinforce the other's
expectations (e.g., excessive need for approval) when this leads to com-
pliance with the former's wishes.
Ellis assumes that 10 core irrational beliefs mediate people's dys-
functional responses to their environments (Ellis, 1962). Although mea-
sures of these beliefs have been found to correlate with indices of psy-
chopathology such as depression (LaPointe & Crandell, 1980; Nelson,
1977), restricting one's assessment and treatment to that set of cogni-
tions may result in overlooking other unrealistic expectations that play
important roles in marital dysfunction. Epstein and Eidelson (1981)
found that self-report scales designed specifically to measure unrealistic
expectations about relationships were better predictors of clinical cou-
ples' levels of marital distress, desire to maintain rather than terminate
the relationship, preference for marital versus individually-oriented
treatment, and self-perceived chance for improvement of the marital
problem than were scales from Jones's (1968) measure of Ellis's irrational
beliefs about self. Consequently, cognitive assessment in marital thera-
py is likely to be more comprehensive if it includes such expectations
about relationships (e.g., disagreement between partners is destructive
to the relationship, partners should be able to sense each other's needs
and moods as if they could reach each other's mind, and partners are
not capable of changing). Other relevant expectations regarding rela-
tionships involve qualities of romantic love, marital roles, and the
amount and quality of time partners will spend together Oacobson &
Margolin, 1979; Stuart, 1980).
110 NoRMAN EPSTEIN
Stuart (1980) notes that an individual's negative (or positive) expec-

tations easily can become self-fulfilling prophecies, as these expectations
guide actions toward the partner and elicit the anticipated responses
from him or her. Although negative self-fulfilling prophecies make the
couple's world more predictable, they are likely to exacerbate marital
conflict and dissatisfaction. Unrealistically positive expectations also are
likely to generate distress when the realities of married life fail to meet
one or both partners' standards.
Sager's (1976) concept of "marriage contracts" is consistent with a
cognitive view of marital conflict. According to Sager, each partner
brings to the relationship a set of expectations, both conscious and be-
yond awareness, regarding the benefits he or she will give and receive.
These expectations, whether realistic or unrealistic, often are unspoken,
but when the realities of the couple's interactions do not meet such
implicit expectations spouses respond (e.g., with disappointment, an-
ger, attack) as if an explicit agreement had been violated. Sager's
therapeutic interventions are intended to make the spouses aware of
their individual expectations or "contracts" and how these mesh or
conflict with the partner's contract and with their actual marital interac-
tions. Foci for change may include individual expectations (e.g., a
spouse's assumption that he or she must receive unqualified acceptance
from the partner might be challenged and modified) or the couple's
pattern of interaction (e.g., an overly critical spouse may be coached in
expressing criticism in a constructive manner that is palatable to a sensi-
tive partner).
A comprehensive assessment of expectations relevant to marital
dysfunction should include commonly held irrational beliefs such as
those postulated by Ellis (1962), common unrealistic expectations about
relationships (Epstein & Eidelson, 1981; Jacobson & Margolin, 1979),
and expectations that are more idiosyncratic to the members of a particu-
lar couple. Beck's idiographic approach to assessing dysfunctional cog-
nitions (Beck, 1976; Beck, Rush, Shaw, & Emery, 1979) consists of sys-
tematic inquiry in clinical interviews, combined with clients' record
keeping regarding their cognitions (thoughts and visual images), emo-
tions, and behaviors in particular situations. Assessment is designed to
identify specific cognitive distortions of events (automatic thoughts) and
basic underlying assumptions. Applying this approach to marital in-
teraction, a therapist may, for example, note a husband's negative mood
in response to his wife's criticism and may draw out the husband's
distorted appraisal that his wife thinks he is an inadequate husband.
Identification of similar instances in which the husband interprets his
wife's disagreement or criticism as total rejection may lead the therapist
COGNITIVE THERAPY WITH COUPLES 111
and husband to explore expectations underlying these negative in-

terpretations, such as, "In order to be a successful, adequate husband, I
must satisfy my wife in every way." Accurate assessment of underlying
expectations requires that the interviewer use questions carefully in
order to go beyond superficial descriptions of thoughts and thereby
obtain samples of the central meanings that events have for the indi-
vidual (Becket al., 1979).
Modification of unrealistic expectations involves systematic reality
testing and examination of how spouses' beliefs inevitably produce dis-
appointment or restrict their ability to solve problems. On the one hand,
a therapist can suggest directly to a spouse that a particular expectation
is extreme and contributes to marital distress. Bibliotherapy can be used
as an adjunct to therapist interventions; for example, couples who have
sexual dysfunctions and hold unrealistic expectations regarding sexual
performance may be instructed to read literature espousing more realis-
tic views of sex, such as the volumes by Barbach (1976); McCarthy,
Ryan, and Johnson (1975); and Zilbergeld (1978). Such material can be
assigned as homework and discussed during marital therapy sessions.
Clients may be more highly motivated to challenge their own beliefs if
the therapist guides them in exploring how these cognitions exacerbate
frustration and conflict in their marriage.
Systematic and repeated reality testing often is necessary to modify
firmly established cognitions that may have served as self-fulfilling
prophecies in the past. Beck et al. (1979) note that the effectiveness of
directly telling a client that his or her expectations are invalid may be
limited because an individual's cognitions may lack external validity but
may be internally valid (consistent with his or her other cognitions and
experiences). Therefore, a direct verbal attack on the person's way of
organizing reality may elicit confusion and anxiety. Confusion and de-
fensiveness can be minimized by interventions in which the couple
learns through here-and-now experiences the degree to which their ex-
pectations are accurate.
Becket al. (1979) note that reality testing is not intended to produce
unrealistically optimistic expectations on the part of clients but to test
the validity of negative or extreme expectations. Therapists and clients
collaborate in examining specific evidence that is consistent or inconsis-
tent with each cognition associated with a presenting problem. The
therapist can ask a series of questions that guide the client in testing
expectations against logic and his or her life experiences. Eliciting facts
that clients may have overlooked or discounted in jumping to conclu-
sions may facilitate a reassessment of such dysfunctional cognitions.
Although the task of modifying unrealistic expectations may be difficult
112 NORMAN EPSTEIN
when they are shared by two spouses, the potential for uncovering
evidence contradictory to the beliefs can be greater when the therapist
can use both spouses as· sources of data.
A major approach for challenging unrealistic expectations is reality
testing by means of behavioral experiments in which spouses are guided
in creating new data bearing on the validity of their negative cognitions
(Beck et al., 1979; Stuart, 1980). Stuart stresses that changes in micro-
behaviors, high-frequency events in a couple's daily interaction pattern,
contribute significantly to changes in the spouses' perceptions of each
other's level of interest and acceptance. By focusing the couple's atten-
tion on positive behavior exchanges and by translating global com-
plaints into specific behavioral goals, the therapist works to instill a
belief that change is possible and to counteract negative expectations
about the relationship ijacobson & Margolin, 1979; Stuart, 1980). Simi-
larly, spouses can be coached in experimenting with alternative ways of
interacting in order to determine the differential consequences. For ex-
ample, spouses who expect that open disagreement will damage their
marriage can be trained in communication skills (e.g., Guerney, 1977)
that facilitate expressiveness without negative consequences. The de-
gree to which the effects of open communication disconfirm spouses'
negative expectations can be monitored during therapy sessions and at
home. Becket al. (1979) note that in order to subject a belief to experi-
mental test, it must be translated into operational terms; for example,
the expectation that "My husband wants to dominate me and will fight
my attempts to assert myself" could be operationalized as "My husband
will yell at me and refuse to negotiate if I tell him I want to take turns
drawing up the monthly family budget." The client's task is to carry out
the prescribed behavior and keep a detailed record of the behavioral,
cognitive, and emotional consequences. An advantage of constructing
such behavioral experiments during conjoint maritaltherapy sessions is
that the other spouse is at least indirectly challenged to behave in a
manner that will disconfirm the partner's negative expectation.
Another method for increasing flexibility in a couple's expectations
regarding relationships is the modeling of alternative relationship pat-
terns by a co-therapist pair. Although co-therapy is expensive and may
require that the therapists invest considerable effort in the development
of their own working relationship (Luthman & Kirschenbaum, 1974),
interaction patterns modeled by co-therapists can facilitate couples' ex-
perimentation with alternative behaviors and expectations regarding
marriage (Epstein, Jayne-Lazarus, & DeGiovanni, 1979; Epstein & Jayne,
1981).
It should be noted that some of the above interventions focus di-
rectly on cognitive content (identifying distortions and errors in think-
CoGNITIVE THERAPY WITH COUPLES 113
ing) and other procedures use behavioral experiences to shift problema-

tic expectations. The common goal of the predominantly cognitive and
the behaviorally-oriented interventions is reality testing of faulty cog-
nitions.
Therapists also need to identify when negative expectations are
reality-based; for example, when a spouse expects the partner to reject
his or her attempts at assertiveness and in fact the partner reacts quite
negatively. In such situations, procedures to modify the quality of the
individual's assertive behavior, the partner's interpretations of that be-
havior, and the partner's social skills (e.g., for negotiating) would be
appropriate.
In addition to specifying and modifying spouses' unrealistic expec-
tations regarding themselves and their relationship, it is important for
the course of therapy to consider potentially problematic expectations
regarding the process of therapy itself. Jacobson and Margolin (1979)
stress that behavior change programs are unlikely to be successful un-
less members of a couple expect to work collaboratively toward mutual
change, with a minimum of blaming. In order to instill such a collabora-
tive set during the initial stage of therapy, Jacobson and Margolin in-
crease the couple's attention to relationship strengths, facilitate some
positive interaction between partners in the first session (e.g., by asking
them to recount how they met and what attracted them to each other),
express optimism about the outcome of therapy, and emphasize how
the partners can elicit more positive behaviors from each other by behav-
ing positively themselves. When spouses expect that feelings must
change before behaviors can be changed, this assumption is challenged
as well, and they are encouraged to enact behavior changes that can
elicit more positive feelings.
Doherty (1981) presents a cognitive model in which spouses' expec-
tations of efficacy or mastery in solving their problems are a function of
their attributions regarding the causes and characteristics of the prob-
lems. For example, the expectation that a problem behavior can be
changed is likely to be stronger when the behavior is seen as voluntary
rather than involuntary and transitory rather than stable. The next sec-
tion of this paper discusses dimensions with which couples attribute
meaning to their behaviors and describes approaches to modifying dys-
functional attributions.
Correcting Faulty Attributions

Distressed spouses not only tend to exchange high rates of negative
behaviors but also are prone to making negative attributions about each
114 NoRMAN EPSTEIN
other's behavior. These attributions often are generalized to the extent

that the individual applies a narrow range of primarily negative dimen-
sions in evaluating the partner (Beck, 1980) and tends to notice or
"track" the partner's negative behaviors while failing to notice positive
behaviors Oacobson & Margolin, 1979). Another common cognitive pro-
cess that can interfere with a behavior change program occurs when a
spouse notices a desired change on the part of the partner yet discounts
its value, concluding that the partner's underlying personality or intent
has not changed. Behavior changes that are attributed to coercion or
impression management (e.g., "He's doing more chores around the
house because he's afraid I'll leave him if he doesn't") are less likely to
be received as positives, and Jacobson and Margolin (1979) suggest that
such negative attributions even can be fostered by contingency contract-
ing procedures in behavioral marital therapy. Gelles and Straus (1979)
note that, at the extreme, attributions of malevolent intent can contrib-
ute to violence among family members. Consequently, correction of
spouses' faulty attributions and perceptions of each other is an impor-
tant step in establishing and maintaining a mutually satisfying relation-
ship.
The attributions that couples make regarding the source(s) of their
problems are likely to influence their optimism and motivation for thera-
py. For example, attributing responsibility for the problem to one's part-
ner, particularly when the attribution involves negative intent, is likely
to elicit destructive blaming (Doherty, 1981). When problems are at-
tributed to stable or global (trait) characteristics of the partner, the indi-
vidual's confidence that the problem can be resolved will be lower and
his or her negative response to the partner may be generalized to vari-
ous aspects of the relationship. An example of the latter phenomenon is
when a husband interprets his wife's getting a job as reflecting a general
lack of respect for his alility as a provider (and therefore his masculinity)
and then becomes quite jealous whenever she talks to another man.
Attributing the responsibility for marital dysfunction primarily to
oneself can be problematic as well. On the positive side, the tendency to
blame the partner should be lower. Similarly, the estimate of potential
for solving the problem should be higher when one's own problematic
behaviors are perceived as voluntary (Doherty, 1981). However, attribu-
tions to global or stable characteristics of the self are likely to lead the
individual to perceive generalized problems (e.g., "I am not only impo-
tent sexually, but probably cannot please my wife in any aspect of our
relationship") for which there is limited hope of improvement.
Hurvitz (1970) systematically challenges attributions that involve
"terminal hypotheses," explanations suggesting no avenues for change.
By asking a series of "Why?" questions, Hurvitz stresses to a couple
how their terminal hypotheses (e.g., "He inherited a bad temper") are
inconsistent with their participation in change-oriented therapy and
challenges them to generate "instrumental hypotheses" that imply po-
tential for problem solving (e.g., "We seem to snap at each other when
we have had little time for relaxation"). Rush, Shaw, and Khatami (1980)
ask each member of a couple to keep a log of marital interactions associ-
ated with unpleasant emotional responses. They then elicit each mem-
ber's assumptions and interpretations about each event during conjoint
sessions and test these against the partner's cognitions. This reality
testing of interpretations each spouse had feared to express can reduce
negative views of self and other, anxiety about rejection, and hostility.
In order to reduce mutual blaming, Baucom (1981) explains to cou-
ples how marital problems can be attributed to internal factors (self) or to
external factors (e.g., partner) and coaches them in assessing how their
own cognitions and behaviors contribute to specific problems in their
relationships. On the other hand, Beck et al. (1979) guide overly self-
critical depressed individuals toward reattributing causes of problems to
factors outside themselves. The techniques used include identifying and
evaluating the validity of "facts" the person uses in assigning blame,
demonstrating how the person applies harsher standards for his or her
own behavior than for others' behavior, and challenging the belief in
total responsibility for negative consequences. Baucom (1981) also works
to counteract attributions made to global and stable factors by having
couples analyze their marital problems in terms of specific and unstable
determinants. The common goal in all of the above interventions is to
shift and expand spouses' perspectives in interpreting the meanings and
causes of their behavior.
Some misattributions in marital interaction can be due to systematic
distortions in thinking such as those described by Beck (1976). Personal-
ization, the tendency to overestimate the degree to which events are
related to oneself, may lead an individual to assume indiscriminately
that he or she has caused the partner's bad moods. Dysfunctional conse-
quences of personalization include aversive self-derogation, defensive-
ness, and depression. The partner who receives such an egocentric re-
sponse is likely to feel misunderstood and frustrated.
A second form of distorted thinking is polarized or dichotomous
thinking, in which people attribute extreme characteristics to themselves
and their partners. The individual whose perceptions are channeled by
such absolutes (e.g., "He never pays any attention to me") may overlook
gradations of behavior and have a low expectancy for change in the
marriage. Partners who are accused of extreme behavior tend to respond
in anger when they perceive that their "good efforts" have been over-
looked. Other thinking distortions that can lead to inaccurate attribu-
116 NoRMAN EPSTEIN
tions regarding a partner's behavior include selective abstraction (focus-

ing on a detail out of context), arbitrary inference (jumping to a conclu-
sion in the absence of evidence or in the face of contradictory evidence),
and unjustified overgeneralization from a single incident. Beck (1976)
suggests that when people apply these absolute, broad, personalized
cognitive "rules" in interpreting, evaluating, and attempting to influ-
ence their own behavior and that of others, the consequences are dis-
turbed emotions and behaviors. The therapeutic task is a collaboration
between therapist and clients in identifying problematic thinking distor-
tions and substituting more realistic, adaptive rules. The therapist works
to instill the idea that thoughts are hypotheses rather than facts, helps
the client(s) identify attitudes and assumptions that seem to elicit nega-
tive emotions and behaviors, and coaches clients in challenging dis-
torted cognitions through logic and in vivo reality testing. As suggested
earlier in the present paper, the monitoring of spouses' cognitions dur-
ing marital interactions in conjoint therapy sessions offers repeated op-
portunities for identifying and modifying problematic distortions.
A common cognitive restructuring procedure used with couples
Gacobson & Margolin, 1979; Stuart, 1980) involves relabeling (or finding
a new attribution for) behaviors that spouses find distressing. For exam-
ple, Jacobson and Margolin describe how a wife misattributed her hus-
band's lack of expessiveness to a lack of trust or love, when in fact it was
due to a deficit in expressive skills. In such a case, relabeling itself may
reduce the couple's distress by identifying a more benign explanation
for a distressing behavior. However, it also is important to address the
wife's desire for verbalizations of love by means of appropriate interven-
tions such as communication training. The process of relabeling begins
with identification of the intent attributed to the partner. It is particu-
larly useful to elicit descriptions of the negative attributions made about
specific instances of the partner's behavior during conjoint therapy ses-
sions. The partner can then provide feedback regarding his or her own
intentions, feelings, and goals associated with the behavior (Rush,
Shaw, & Khatami, 1980). Of course, the attributions the partner makes
about his or her own behavior themselves may involve problematic
distortions that must be addressed (e.g., trait attributions that imply
inability to change). Nevertheless, at times it may be less important to
determine which attribution is more accurate than to instill the attitude
that attributions are subjective and susceptible to error. Couples can be
coached in the use of communication skills (e.g., Gottman, Notarius,
Gonso, & Markman, 1976; Guerney, 1977) designed to increase each
spouse's understanding of the other's perspective and thereby decrease
misinterpretation.
Stuart (1980) suggests that it can be beneficial for therapists to dis-
tort attributions for spouses' behaviors in a positive direction, in the

interest of eliciting positive emotions and interactions. It seems that this
approach should be applied quite judiciously, because it could backfire
by leading a spouse to perceive the therapist as allying with a negative
partner or by leading one or both spouses to question the therapist's
observational ability.
The goal of decreasing aversive interaction and increasing positive
interaction in behavioral marital therapy is likely to be facilitated signifi-
cantly by the assessment and modification of attributions that contribute
to the perception of behaviors as negative or unchangeable. Such an
approach involves teaching couples that marital satisfaction is a subjec-
tive state influenced by idiosyncratic interpretations of day-to-day in-
teractions. Attributional change can be both a prerequisite for and a
consequence of positive behavior change.
Teaching Self-Instructional Procedures

Interactions of highly distressed couples commonly are marked by
emotional outbursts and escalating exchanges of aversive behavior. Al-
though such behavior may be determined in part by distorted expecta-
tions and attributions that elicit negative emotions such as anger and
anxiety, the particular impulsive form of the behavioral response is itself
problematic in that it impedes the reflective processes needed to test
faulty cognitions. Impulsive interaction between emotionally aroused
spouses also interferes with systematic problem-solving skills that could
reduce distressing conflict. Behavioral marital therapy procedures such
as communication training, problem-solving training, and contingency
contracting, which are intended to decrease exchanges of aversive be-
haviors, can be difficult to implement unless spouses are able to direct
and control their responses to each other. A communication training
program such as Guerney's (1977) Relationship Enhancement helps
slow impulsiveness by imposing strict interaction rules, but success with
such an intervention presumes a certain level of self-control under
stressful conditions; that is, the mere presence of the partner can elicit
strong, task-interfering emotional and behavioral responses in highly
distressed couples (Epstein & Williams, 1981).
In marital treatment, conjoint sessions provide opportunities to as-
sess cognitive excesses and deficits. However, in cases where a spouse's
self-regulatory ability is so impeded that he or she continually disrupts
conjoint sessions, individual self-instructional training may be a neces-
sary prerequisite.
Meichenbaum (1976, 1977) describes procedures for assessment and
118 NoRMAN EPSTEIN
training of self-instructional skills for use in inhibiting impulsive re-

sponses, focusing attention on task-relevant cues, attending to task
goals, coping with frustration and failure, and controlling specific verbal
and nonverbal behaviors needed to accomplish the task. Couples who
respond impulsively toward each other can be taught how their unregu-
lated behavior interferes with fulfillment of their needs in the relation-
ship, trained to recognize cues of impulsive or otherwise unconstructive
behavior early, and coached in the development of positive cognitive
and behavioral coping responses. Each spouse has the task of noticing
cues on his or her own part (e.g., anger, anxiety, confusion, rapid
speech, interrupting the partner, and thoughts about winning an argu-
ment) and cues exhibited by the partner (Epstein & Williams 1981). The
therapist initially can provide the couple with feedback regarding such
cues, and videotape replay of sessions can be used to "relive" situations
that elicited maladaptive cognitions, emotions, and behaviors. Spouses
then are instructed to use the identified cues as discriminative stimuli for
positive self-instruction, which can include statements describing the
steps involved in a task and how to accomplish them. For example, self-
instruction during a communication training task might include
(1) identification of impulsive responses (e.g., "I am interrupting my
partner") and task-interfering cognitions (e.g., "I am thinking about
how my partner's ideas are incorrect"), and (2) self-instruction for effec-
tive completion of the task (e.g., "Stay calm. Listen carefully to my
partner and try to understand how she views things. Do not respond
with my ideas until I have communicated understanding of my partner's
views to her"). Interventions by the therapist include specific instruc-
tions for generating positive self-statements, modeling of overt self-in-
struction, and coaching of clients' own rehearsals. There should be a
progression from overt to covert self-instruction, and couples are more
likely to develop proficiency with these skills if they have opportunities
to practice them while discussing relatively benign topics before pro-
gressing to emotion-laden relationship topics.
Stress inoculation training, which teaches clients to cope with
stressors by means of self-instruction, imagery, and behavioral skills
(Meichenbaum, 1977), can be used to reduce spouses' maladaptive re-
sponses to stressful marital conflict and its concomitant negative emo-
tions such as anger and anxiety. Meichenbaum (1977) describes a three-
phase model of stress inoculation in which clients are educated in a
conceptual framework regarding stress responses, rehearse a variety of
cognitive and behavioral coping techniques, and then apply the skills
with real stressors. The training and rehearsal phase includes coping
techniques for four stages: preparing for a stressor, confronting and
handling it, coping in the event of being overwhelmed by the stressor,

and reinforcing oneself for successful coping. Behavioral coping tech-
niques include planning an "escape route" (e.g., going out for a walk)
and use of physical relaxation. Cognitive coping involves monitoring
one's negative self-statements (e.g., ''I'll lose control") and using their
occurrence as cues for emitting positive, coping self-statements (e.g.,
"Just relax and take one step at a time").
Stress inoculation training can be applied with distressed couples
for whom interaction has come to elicit anxiety sufficient to impede
communication and problem-solving. Novaco's (1975) use of stress inoc-
ulation for controlling anger arousal also can be valuable in reducing
spouses' destructive ways of responding to marital conflict. Clients are
taught relaxation skills to reduce arousal and cognitive skills for coping
with provocations. They are taught to identify anger-eliciting self-state-
ments (e.g., intolerance for the partner's mistakes, perceived threats to
self-worth) and to substitute constructive self-statements.
Assessment of the need for stress inoculation training to reduce
problematic anxiety and anger in marital conflict is best accomplished in
a conjoint session, where the therapist can observe how debilitated each
spouse is when interacting with the other. In fact, the couple's own
negative experiences during the interaction can be used to support the
rationale for the training. The initial rehearsal of self-instructional skills
is best done individually rather than with in vivo marital interaction, and
some spouses with severe anxiety or anger responses may need indi-
vidual therapy before they can work collaboratively with their partners.
However, with many couples even the initial rehearsal of skills can be
conducted with both partners present but working individually with the
therapist rather than interacting. Advantages of this format are that
spouses learn coping skills both by rehearsing and by observing their
partners rehearsing, and they increase their understanding of each
other's cognitions and emotional reactions. Individual skills then can be
monitored and practiced in actual marital interaction, with the therapist
instructing, providing feedback, modeling, and coaching the couple as
needed.
COGNITIVE INTERVENTIONS, BEHAVIORAL INTERVENTIONS

AND SYSTEMS THEORY
Cognitive and behavioral approaches to therapy traditionally have

been designed to modify the dysfunctional thoughts and skills of indi-
viduals through processes of relearning. Although cognitive and behav-
120 NORMAN EPSTEIN
ioral interventions with individuals may not seem consistent with goals
of marital therapists who are guided by concepts of systems theory, a
cognitive-behavioral model of marital interaction has some important
areas of overlap with a systems orientation.
The cognitive interventions described in this paper are intended to
modify distortions, deficits, and excesses characteristic of the individual
spouse, but it is assumed that these dysfunctional cognitions continually
influence and are influenced by interdependent sequences of behaviors
between spouses. Each partner's emotional and behavioral responses to
the other are mediated by his or her cognitive appraisal of the partner's
behavior. In terms of marital conflict, negative behaviors elicit negative
cognitions, and vice versa. The argument that behavioral change will
produce attitudinal change (Stuart, 1980) is limited with highly dis-
tressed couples whose expectations and attributions are very negative.
Reduction of behaviors identified by spouses as distressing may not
produce greater marital satisfaction if negative cognitions have not been
changed (e.g., "He helps more around the house now, but r.e still
doesn't want to help"). Cognitive interventions such as relabeling of
behaviors for which there are negative attributions may be necessary
before spouses will be motivated to change their behavior (Jacobson &
Margolin, 1979). Similarly, negative cognitions are unlikely to change if
they are supported by the "evidence" of continued negative behavior.
Change in the marital system depends on changes in sequences of cog-
nitions and behaviors occurring between spouses.
Feldman (1976) describes how cognitions and behaviors interact in a
marital system, such that complementary cognitive schemata (e.g., atti-
tudes and expectations about oneself and relationships) are elicited in
the two spouses in the course of their behavioral interplay. Each behav-
ior on the part of one spouse simultaneously is a response to the part-
ner's behavior and the person's own cognitive schemata, a stimulus for
the partner's subsequent behavior and schemata, and a reinforcer of the
preceding couple interaction. Feldman identifies a circular pattern in
couples involving a depressed member, such that the nondepressed
member's behavior (perhaps a critical remark) elicits self-depreciation
and dysphoria in the depressed partner, which then elicits overprotec-
tive cognitions and behavior on the part of the nondepressed member.
However, the depressed partner finds the oversolicitousness not only
reinforcing, but also frustrating to his or her own desire for competence.
Any consequent withdrawal or hostility expressed by the depressed
partner then elicits cognitions of self-depreciation in the nondepressed
partner, who is likely to engage in depression-inducing behavior and
thereby begin the cycle once again. Spouses can initiate the repetitive
CoGNITIVE THERAPY WITH CouPLES 121
pattern at any behavioral or cognitive point in the sequence, and treat-

ment should take into account each step in the sequence: the non-
depressed spouse's cognitions (threats to the self-image of rescuer) and
behaviors (criticism, oversolicitousness), and the depressed spouse's
cognitions (self-depreciation) and behaviors (self-criticism, withdrawal).
The determinants of any one component of the cycle are understood by
examining the total interactive system.
Dryden (1981) suggests that cognitive, behavioral, and systems ori-
entations to the treatment of couples' problems can be integrated by
challenging spouses' faulty inferences and beliefs regarding their rela-
tionship, teaching them social skills to reduce negative interactions, and
modifying the responses of each partner that may reinforce undesirable
behavior on the other's part. Stuart (1980) describes a sequential model
of cognitive and behavioral interventions, in which cognitive changes
are induced in order to facilitate new behaviors, behavior changes are
initiated to produce new (more positive) subjective experiences, and
cognitions likely to encourage repetition of new desired behaviors (e.g.,
recognition of a partner's positive response; attribution of positive in-
tent) are developed.
Thus, the marital therapist must be skilled in modifying both inter-
nal cognitions and overt interactions between spouses. The cognitive
approaches presented in this chapter can be combined with behavioral
marital therapy procedures such as communication training and prob-
lem-solving training in order to produce positive cognitive and behav-
ioral changes in distressed couples. For example, relabeling negative
attributions can decrease hostility and facilitate empathic communica-
tion, and development of cle~u communication can provide evidence to
contradict negative expectations about one's relationship. Similarly, self-
instructional training can facilitate behavioral problem-solving skills by
focusing performance and decreasing task-interfering thoughts and
emotions, and cooperative efforts in problem solving can build positive
expectations and attributions regarding one's partner. The therapist's
task is to implement mutually enhancing changes in spouses' cognitions
and behaviors.
By integrating cognitive and behavioral interventions in a conjoint
setting, the martial therapist has the advantage of a multidimensional
approach to complex marital interactions. Although the cognitive ap-
proaches described in this chapter represent extensions of established
cognitive therapies for individuals, their application with couples has
been derived in clinical practice and has yet to be tested empirically.
Consequently, they should be applied with caution until their efficacy
has been investigated in treatment outcome studies. In order to do jus-
122 NORMAN EPSTEIN
tice to the complexity of intervening in a marital system involving inter-

dependent behaviors and cognitive structures, such studies should not
fail to include multidimensional assessment and examination of se-
quences of cognitive and behavioral responses in the dyad.
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Beck, A. T. Cognitive aspects of marital interaction. Paper presented at the annual meeting of
the Association for the Advancement of Behavior Therapy, New York, November
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Guilford, 1979.
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7
Cognitive-Behavioral Strategies
to Induce and Enhance a
Collaborative Set in Distressed
Couples
JANIS LIEFF A BRAHMS
This chapter illustrates the complexity of interpersonal conflict. Rela-

tionship dissatisfaction often is a product of both intrapersonal and in-
terpersonal deficiencies. Both cognitive and behavioral interventions,
therefore, may be uniquely suited to increase partners' subjective valua-
tion of their relationship.
When both spouses first are treated in individual therapy, they are
encouraged to focus on themselves, to examine thoughtfully the futility
of their present attitudes and behaviors, and to make appropriate
changes vis-a-vis their marital partner. Subsequent conjoint sessions
may be indicated, as will be discussed later. Cognitive and behavioral
interventions intermesh to produce a cogent, comprehensive treatment
package.
Whether to treat individuals separately or together as a couple, and
to focus on idiosyncratic and dysfunctional needs and expectations ver-
sus interpersonal behavioral deficits and excesses, involves decisions
that are highly intricate, delicate, and controversial. The ideas presented
admittedly are speculative, based on the author's clinical experience
with distressed couples.
jANIS LIEFF ABRAIIMS • Department of Psychology, Yale University, New Haven, Con-
necticut 06520.
125
126 JANIS LIEFF ABRAHMS
COLLABORATIVE SET
The term collaborative set recently was defined by Jacobson and Mar-
golin (1979) according to a social learning and behavior exchange model:
"Both spouses must conduct themselves as if they viewed their relation-
ship difficulties as a common problem which can be solved only if they
work together" (p. 108). The Random House Dictionary (1966) employs the
interpersonal connotation of the word collaborate with this definition: "to
work together ... to co-operate with the enemy" (p. 289).
In the cognitive-behavioral (CB) treatment of couples, the indi-
vidual is assisted in realizing the full complex of factors which contribute
to marital disease, along with the degree to which ones' own maladap-
tive cognitions constitute "the enemy." Such cognitions consist mainly
of dysfunctional expectations, attributions, and ideas regarding oneself,
one's partner, and one's relationship. Collaboration in this context is
viewed as an individual's conscious decision, responsibility, and effort,
a demonstrated willingness to work for the good of the relationship
regardless of one's spouse's alleged feelings or reciprocated actions.
BUILDING A COLLABORATIVE SET THROUGH INDIVIDUAL

COGNITIVE RESTRUCTURING
Problem solving and communication training are virtually impossi-

ble to accomplish if a couple is unwilling to collaborate. According to
Jacobson and Margolin (1979), "faculty attributions [e.g., "my spouse is
the enemy"] often need to be corrected before spouses will enthusi-
astically engage in a collaborative effort to modify undesirable relation-
ship behavior" (p. 142). Couples often enter therapy viciously blaming
each other for the problems in the marriage and stubbornly waiting for
their partner to initiate positive change.
Maladaptive, interpersonal attitudes must be sensitively exposed
immediately. Behavior therapists who begin sessions by having couples
trade off "low cost" behaviors may not be cognizant of the fact that any
positive behavior change for some spouses is simply too risky and un-
pleasant. Too many cognitive obstacles may exist for marital partners to
be willing to experiment with behavior change-particularly in front of
each other. Therefore, if the therapist tries to induce an experimental
attitude by encouraging the couple to act more constructively toward
one another, his or her effectiveness may be deflated or sabotaged un-
necessarily and unfortunately.
Individual versus conjoint sessions may provide a more conducive,
COGNITIVE-BEHAVIORAL STRJ\ TEGIES 127
therapeutic environment for each spouse to focus on himself or herself

(Abrahms, 1982) and to consider with less distraction the basic thrust of
the cognitive model: one's individual responsibility in creating dissatis-
faction by adhering to dysfunctional relationship expectations and
ideas. Premature conjoint sessions may create a no-win trap: either the
partners reject the therapy and continue to blame each other for their
misery (a self-defeating point of view which originally may have
brought the couple into therapy), or they must admit their culpability to
their spouse.
Particularly in the early stage of treatment, CB therapy may be more
efficacious if persons are seen individually rather than as couples. As
spouses identify and challenge their flawed cognitions, they might
loosen their ingrained, bitter, pessimistic postures and allow themselves
to establish a motivational commitment to the marriage and therapy.
Many people need time to review the advantages and disadvantages of
blaming their partner for their unhappiness, harboring grudges, and
refusing to initiate positive action. Couples often are mentally unable
and unwilling to engage in an experimental "as if" attitude, acting "as
if" the marriage were viable and "as if" they felt loving. It is the thera-
pist's task to break through this resistance by restructuring the couple's
defeatist attitude. Moreover, the therapist should make every attempt to
structure successful marital interactions, minimizing aversive contacts
between spouses.
For some couples, individual treatment sessions might be super-
fluous; for others, however, the establishment of a constructive attitude
might facilitate achievement of the primary, preliminary therapeutic
goals of CB marital therapy: to focus on oneself, to build positive expec-
tations regarding the viability of the marriage, and to build credibility in
the therapist's competency and usefulness of the therapy.
CoGNITIVE CHANGE PoTENTIATING BEHAVIOR CHANGE
Proponents of behavior exchange principles (e. g., Stuart, 1980)

posit repeatedly that the best way to change Partner B's behavior is to
change Partner A's behavior. Retreating one step, cognitive-behaviorists
(e.g., Epstein, 1982) assert that the most effective way to change Partner
A's behavior is first to change Partner A's cognitions. That is, instead of
trying to modify the undesirable behavior of Partner B, an alternative
solution is to increase Partner A's tolerance of his or her spouse's unde-
sirable behavior-particularly since people frequently do not change
long-standing, well rehearsed habits easily or consistently just because
other people find them annoying. Once Partner A realistically assesses

the proportions, meaning, and underlying intent of Partner B' s behav-
ior, the objectionability and importance of the behavior in question may
become dramatically reduced.
For instance, if a husband believes, "If my wife doesn't listen to me
the way I would like her to, she doesn't care about me," one approach
would be to change the wife's listening abilities. A cognitive strategy,
however, would be to modify the husband's perceived need for com-
plete, undivided attention by helping him to identify the inaccurate
meaning he imposes onto his wife's episodic inattentiveness.
The following example illustrates how cognitive restructuring tech-
niques facilitate behavioral solutions. Sam continually dropped wet tow-
els on the bathroom floor, although he was personally well groomed
and kept other household areas quite neat. Every morning, when his
wife Sara entered the bathroom, she became infuriated because she
thought, "What does he think I am? The maid? I work hard, too. He
treats me shabbily. He doesn't give a damn about me." She mistakenly
interpreted his careless habit as a deliberate insult by assuming: "If I ask
my husband to do something important for me, he should listen. If he
doesn't listen and change his behavior, it's because he chooses to dis-
regard me. Thus, he must not respect me or value the marriage."
By directly checking the validity of these thoughts with Sam or by
exploring alternative explanations for his behavior in her own mind, the
upset spouse would discover the true reason for her husband's actions.
In the early morning, he was usually preoccupied. Her mindreading,
therefore, had been off base.
Sara also erroneously assumed that (1) people have free will, and (2)
people change easily and quickly. She consistently upset herself if her
husband deviated from his promises. To challenge her silent assump-
tions, the therapist instructed her to change instantly and permanently
several of her more entrenched habits: binge eating, smoking, nail bit-
ing, nagging, and thinking negative thoughts about her neighbors. A
week later, when she was asked about the ease and degree of com-
pliance in changing these habits, she confronted the unrealistic nature of
her excessive demands.
Once her husband's habit seemed less abusive, her anger dimin-
ished. She then could entertain the following constructive behavioral
options: (1) She could continue to ask her husband to pick up the towels
but not expect him to remember. (2) She could post notes with the hope
that he would read and follow them but, again, not expect him to re-
member. (3) She could let him remind himself and try not to upset
herself when he forgot. (4) She could positively reinforce him if he did
COGNITIVE-BEHAVIORAL STRATEGIES 129
remember, in an attempt to increase the probability that he might re-

member in the future.
Here the sequential use of cognitive followed by behavioral meth-
ods illuminated and sustained each strategy's beneficial effects. As
spouses take more responsibility for their own negative feelings, they
achieve better control over their emotions, increase their capabilities to
act more positively toward their partner, and potentially increase the
probability of eliciting more positive reactions from their partner.
Three detailed examples are presented below to demonstrate the
usefulness of (1) individual cognitive restructuring to develop a collab-
orative set prior to conjoint therapy and (2) integrating cognitive and
behavioral interventions to facilitate positive change within couples. The
first example, a clear case failure, describes a couple that was insuffi-
ciently induced to accept their individual contribution to their marital
dissatisfaction. When brought together, they became embroiled in ac-
cusatory, deprecating, interpersonal attacks that ultimately aborted the
therapy sessions. The second example represents a more successful in-
tertwining of individual self-examination and behavioral exchange. Fi-
nally, a third example illustrates how dysfunctional relationship expec-
tations depress a relationship's perceived viability.
CASE 1. FAILURE TO INDUCE ADEQUATELY A COLLABORATIVE SET
John and Nancy Smith, a couple in their mid-forties, entered

therapy complaining that their marriage was deficient across all
areas of functioning: sexual, affectionate, communicative, and recre-
ational. What existed between them was a sizzling rage, triggered by
a traumatic incident that had occurred three years earlier while con-
sulting a psychiatrist about their son Joel's delinquent behavior. In
front of their son, Nancy had attacked John verbally for destroying
Joel's self-concept, controlling her life, and deserving the family's
hatred.
John apparently did not attempt to dispute her accusations.
Feeling ashamed and ruthlessly abused, he silently castigated his
wife for creating an irreparable schism between them and between
him and his children. Since that incident, the couple continued to
move apart, leading parallel lives and making contact only through
fighting.
Two years elapsed, during which time the couple's two daugh-
ters demonstrated significant improvement in individual CB thera-
py. At a family session on behalf of the children, the parents ex-
pressed interest in couples therapy. They seemed somewhat moti-
vated to repair their relationship, yet skeptical that anything or any-
one could reverse its erosive decay.
The Interfering Effect of Underlying Cognitions on a Behavioral

Experiment
At the first session, a gestalt of the couple's relationship evolved
that included both strengths and deficiencies during various stages of
the marriage. The therapist explained behavior exchange and cognitive
principles and attempted to generate a present-oriented, experimental,
nonevaluative attitude on the part of the couple. The Smiths identified
concrete and positive areas of change and agreed as a first homework
assignment to exchange relatively low-cost behaviors. Each spouse
agreed to take responsibility for his or her own behavior assignment,
making such change noncontingent on the other's behavior. This clause
was intended to cut through the typical "you, first" attitudinal impedi-
ment. Specifically, John agreed to discard his cigarette at the half-way
mark. Nancy agreed to invite a mutually chosen neighborhood couple to
a movie the following weekend. Thus the exchange entailed improve-
ment in John's personal grooming habits and in Nancy's involvement in
their leisure time activities. Both partners expressed credibility in the
feasibility and significance of the experiment.
The therapist further explained that any outcome would yield valu-
able information that would be used in the next session. This statement
was made to encourage the return of both partners, regardless of their
cognitive and emotional reactions to the results of the experiment. Im-
plicitly, the experiment was designed to inject fresh blood into the rela-
tionship and/or to assess the couple's ability to collaborate.
When the couple returned the following week, Nancy had not com-
pleted her homework assignment. She said she felt manipulated by the
experiment and did not want to collaborate for John's sake. It is interest-
ing that the first experiment highlighted what was later found to be a
series of core obstructionist assumptions. Both partners had acted ac-
cording to their underlying beliefs. John believed that only he was genu-
inely interested in improving the marriage. All failure thereby was at-
tributed to Nancy. It might be hypothesized that to substantiate this self-
righteous attitude, he was obliged to complete the homework. John
conveniently used the failure of the first experiment to confirm his pre-
vailing belief.
Nancy believed that to collaborate meant to give up control, and to
give up control was a sign of weakness. The therapist unwittingly had
designed an exercise that presented her with an unbeatable formula:
either she cooperated and experienced a self-devaluation, or she re-
jected the task and was blamed by her spouse for ruining their relation-
ship. Although the therapist tried to elicit potential obstacles at the time
of assignment, the wife had not objected. She may not have been aware
of her silent assumptions or of their potency in affecting her behavior. It
is also possible that she passively agreed to cooperate in order to avoid
momentarily her husband's anticipated wrath.
Purpose of Individual Sessions

The therapist decided to see the couple individually for a number of
reasons: (1) The couple had adopted a fixed, blaming framework that
undermined each partner's ability and willingness to consider indepen-
dently the impact of his or her own attitude and behavior. Pressing self-
scrutiny in the presence of the other partner seemed to exacerbate their
competitive, combative stance. Each continually shifted the focus of
responsibility back onto the other person. (2) Given the couple's reluc-
tance to continue therapy and their pessimism regarding the viability of
the relationship, further perceived failure might have precipitated their
dropping out of therapy permaturely.
Individual cognitive strategies were presented with the following
basic treatment rationale: "Beliefs often paralyze actions. Therefore, it is
important to identify and correct these ideas before partners can work
effectively together."
Both spouses agreed to come in for individual sessions to deal with
their cognitive blocks and resultant resentment prior to learning com-
munication and problem-solving skills. At this point, Nancy seemed
more eager to begin than John. He blatantly admitted that his only
reason for being in therapy was to engage Nancy i~ therapy. He insisted
that for the marriage to survive, she would have to apologize for her
unfair and unpardonable actions in the psychiatrist's office. Nancy
would barely speak to John, never mind apologize.
To perk John's interest in therapy, the therapist suggested that if
Nancy realized his interest in improving the marriage, she might be
more willing to meet his request. John agreed to attend eight individual
sessions, after which he insisted on another conjoint meeting to evaluate
changes in his wife. John wholeheartedly believed he needed Nancy to
vindicate him of his guilt and repair his damaged self-image.
Cognitive-Behavioral Interventions
In order to objectify their hostility and blame, the spouses were
taught to record automatic thoughts and eventually to identify silent
assumptions using the Dysfunctional Thought Form (Beck, Rush, Shaw,

& Emery, 1979). This exercise quickly illustrated that at moments of
intense rage, both partners framed the other as uncaring and condemna-
ble. For example, when John refused to lend his car to one of the chil-
dren, Nancy thought, "He's unwilling to inconvenience himself for his
family. He's selfish." The couple learned to identify such cognitive er-
rors as mislabeling and selective negative focusing which discolored
their perceptions of each other.
To revise more accurately their perspective of each other, they were
asked to record instances of how their spouse demonstrated caring and
interest in his or her own way. This clause prevented disqualifications or
the ignoring of behaviors that challenged the "uncaring" hypothesis.
Nancy listed such items as "asking me about my day at work, taking the
kids to school when they missed their bus, and sharing his view of the
daily news." John listed, among other items: "buying me my favorite
kind of bagel for Sunday morning breakfast, laundering my clothes, and
asking me about my work day." Thus both were able to see how each
had viewed the other as 100% self-centered. They had exaggerated the
frequency with which their spouse demonstrated unacceptable behavior
and their sense of deprivation. It is interesting to note that whereas the
focus of this exercise was clearly behavioral, its impact was cognitive in
that an unsavory relationship was injected with positive highlights. The
couple was forced to reconcile the incongruity between a list of their
partner's pleasing behaviors and their own global dissatisfaction with
that partner.
To prepare for the rapidly approaching conjoint session, Nancy
worked on reattributing her children's problems to a number of factors
besides John's mismanagement of his anger. She identified advantages
and disadvantages of adhering to her prevailing belief: "Joel's emotional
and social problems today are John's fault." The advantages were that
(1) she would not have to relinquish her resentment for John, (2) she
could use John as a scapegoat and blame him for Joel's shortcomings, (3)
she could blame John for Joel's future mishaps, (4) she did not have to
recognize her complicity in Joel's development, (5) by expressing dissat-
isfaction with John, she created a view of herself as the more benev-
olent, rational, well adjusted parent, and (6) she did not have to take
responsibility for improving the marriage. The disadvantages were: (1)
by feeling resentful toward John, she guaranteed no improvement in her
relationship and discouraged herself from initiating better interactions,
(2) she preserved a negatively biased view of the marriage, (3) she
wasted time ruminating over rancorous thoughts, (4) she experienced a
high level of dissatisfaction which eroded the quality of her everyday
COGNITIVE-BElli\ VI ORAL STRATEGIES 133
life, and (5) the marital situation was aversive to the children and pro-
vided poor role models for them.
This self-help exercise motivated Nancy to consider the ill effects
that her past beliefs were having on her present marriage and moved
her to desire actual readjustments in her attitude and behavior toward
John. First, she concluded that the disadvantages of subscribing to the
above dysfunctional belief outweighed the advantages by 80%. She then
was asked to present evidence that disconfirmed the "John is solely to
blame" assumption. She realized that (1) Joel had acted in difficult,
disruptive, and aggressive ways since birth, (2) John had been provoked
by Joel's stubborn defiance into overreacting in inflammatory ways, (3)
this reaction was not based on his disregard for Joel, but rather John's
inability to discipline with more adaptive tactics at the moment, and (4)
although John had communication problems with his family, he showed
them love in other ways.
Since her original blaming perspective was neither helpful nor total-
ly valid, she rewrote it as follows:
John's communication problems may have contributed to Joel's emotional
and social problems, but John tries to be a loving and patient father. Joel,
certainly as an adult, has a responsibility to change his own destructive
attitudes and behaviors rather than to blame his father for his current situa-
tion. John did the best he could given an imperfect child, father, and relation-
ship. I can try to take the initiative to improve the marriage, even if John's
relationship with Joel does not improve.
Another major obstacle to be hurdled involved the pejorative meaning

Nancy ascribed to making decisions jointly. Nancy firmly believed that
to ask John for his opinion would be a sign of personal weakness, as if
her independent judgment were defective. The couple's communication
pattern could not be positively altered until she convinced herself that it
was not helpful to achieve power by excluding John.
Nancy considered the advantages and disadvantages of ostracizing
her husband from the rest of the family. She was unsure of what might
occur if she did include him since it had been some time since she had
acted collectively. Nancy was certain, however, that by systematically
excluding him, she had to deal with his angry recriminations and brood-
ing withdrawal.
She also realized that she had created a self-fulfilling prophecy. She
withheld information and made unilateral decisions. John interpreted
these actions as meaning, "My ideas are unimportant to my wife." He
then withdrew and showed less interest in the family. Finally, she de-
nounced him for having so few constructive familial interactions. In
diagraming this pattern, she concluded that she did not have to be
134 JANIS LIEFF A BRAHMS
magnanimous, but merely self-interested to act more positively toward

John. John also was shown how this negative reinforcing cycle yielded
results that were dichtomously opposed to his wishes.
The therapist further diluted her "cooperation-weakness" formula
by asking the following questions:
THERAPIST: If a person subscribes to a belief that is frequently self-defeating, is it

a sign of strength to continue to subscribe to it?
PATIENT: Of course not. It's not very heroic to maintain crummy habits.
THERAPIST: If a person is willing to experiment empirically with a belief and to
develop a more beneficial belief, even if it takes a great deal of effort, might
she be viewed as acting from a mature and healthy vantage versus a position
of weakness?
PATIENT: I see what you're getting at, but it's hard to accept.
These logical challenges helped Nancy to adopt gradually a more

experimental attitude regarding her interactions with her husband.
Knowing that John felt excluded from and victimized by the family, she
decided to allow him to participate in decision-making and pleasure
oriented activities. For instance, she once left a friendly note, informing
him of the whereabouts of the family and of subsequent dinner plans.
John decided to join the family at the specified site and reacted with
conspicuous appreciation. Nancy realized how her dysfunctional beliefs
had polarized John from the family, a reaction that ran counter to her
desire for him to become more vitally involved. Moreover, his positive
reaction reinforced Nancy's sense of positive control. She thus dis-
covered that by making her husband feel important (according to his
criteria), she gained control in that she positively influenced their mari-
tal experiences.
John's individual therapy progressed along similar lines. The Dys-
functional Thought Form underscored his basic maladaptive marital
views: "I get nothing from the marriage. Nancy doesn't give a damn
about me. She blames me for everything bad in the marriage. I refuse to
change until she proves her love to me." Obscuring a more rational
perspective was his tendency to use selective negative focus and over-
generalization. These cognitive errors were identified and corrected, as
discussed earlier.
The greatest obstacle to John's progress was his defensive and ac-
cusatory posture. He adamantly believed that because he had been gen-
uinely wronged, Nancy would have to make the relationship "right" for
him. Typically, he acted in a sullen or vindictive manner while feeling
quite sanctimonious. He believed that by threatening divorce and by
CoCNITIVE-BEilt\ VI ORAL STRATEGIES 135
viciously upbraiding his spouse for her apparent disinterest in him and
blaming stance toward him, he could "punish her into line."
During the brief period for which the patient contracted, the thera-
pist endeavored to examine and to weaken John's unwavoring philoso-
phy. He listed the advantages and disadvantages of believing: "Nancy
must show significant change before I agree to change. And, not only
must she go first, but go first while I continue to punish her." One
obvious disadvantage was that an entire generation could pass while he
waited for her to initiate positive action. At that moment (although
apparently not integrated over time), he agreed that he had been win-
ning a Pyrrhic victory-in typecasting himself as the "hurt and abused
victim," he had created both justification and misery.
By the end of the eighth session, both partners realized to some
extent how corrosive and self-perpetuating their interactional patterns
had become. Nancy had begun to modify her irrational views that (1)
John was totally responsible for the family's problems, and that (2) col-
laboration on her part meant she personally was incapable of indepen-
dent action. John had begun to perceive the value of controlling his rage
attacks and of initiating positive changes noncontingent on Nancy's
behavior. It was intended that these individual CB therapy sessions
would provide a motivational and educational backdrop for future con-
structive interactions.
Purpose of Conjoint Session

A conjoint session was planned, as originally promised, so that
Nancy could soften the effect of her previous accusations and John could
show appreciation for Nancy's efforts to include him in important family
matters. It was hoped that once this barrier had been successfully
crossed, John could learn to handle criticisms more effectively, and Nan-
cy could learn to handle John's angry outbursts more effectively. Fur-
thermore, each partner could continue to take low-cost steps to enhance
his or her value to one another while eventually acquiring more adaptive
problem-solving and communication skills.
Admittedly, the therapist believed the timing of the conjoint session
to be premature. Yet, because there was some evidence that the couple
understood and embraced the major points made in their individual
sessions, the therapist scheduled a highly structured couples session
with a predetermined, mutually acceptable agenda.
Paradigmatic of cognitive-behavioral therapy, the conjoint session
afforded an opportunity for the couple to gain a realistic perspective of
136 }ANIS LIEFF ABRAHMS
each other, their marriage, and its potential. They could (1) expose and
check out misassumptions, (2) revise faulty accusations, (3) recognize
positive interactions and rebalance a selectively negative bias, and (4)
reattribute a spouse's undesirable behavior to more emotionally defused
and accurate explanations. For example, Nancy excluded John, not be-
cause she viewed him as unimportant, but because of the distorted
meaning she attached to such cooperation. John fought, not because he
despised Nancy, but because he was deficient in handling various frus-
trations and felt unloved. He also expected his verbal attacks to force her
to abide with his demands. (5) Moreover, the spouses could correct their
tendency to mislabel by learning to express their annoyance with the
person's behavior rather than with the person himself or herself. (6)
They also could recognize how their "should" statements reflected arbi-
trary, interpersonal expectations that fueled their anger when their
spouse did not live up to them.
Results of the Conjoint Session

Unfortunately, what ensued in the conjoint session was a repeat
performance of the same habitual attack-counterattack-withdraw cycle
that marked the couple's previous interactional pattern. The couple had
begun fighting the night before the session about matters to be dis-
cussed in it. Nancy told John that she recently had spoken to their son,
suggesting that he leave the home (allegedly for the good of everyone
involved). John became infuriated at the idea that she would take such
significant action without first consulting him. This event triggered his
insufficiently weakened belief that to be excluded was an unpardonable
rejection, that the marriage was worthless if his wife did not confide in
him on all major issues, and that she must not trust or respect his
judgment.
It is unclear whether Nancy acted with intentional malice. She later
admitted that she had planned to discuss this matter with John first, but
had spontaneously spilled her negative feelings to her son in a moment
of confrontation. Nonetheless, John's explosive reaction was perceived
by Nancy as punishment for sharing information with him. John refused
to participate further and the session was terminated. Both felt exceed-
ingly discouraged and misunderstood.
Although the therapist convinced the couple to return for a follow-
up session to illustrate the controlling effect their dysfunctional in-
terpretations had on their emotions and behaviors, neither would agree
to further sessions. Both blamed the other for the failure of the relation-
ship and rejected any notion of using the backfired session as an in vivo,
exemplary learning experience.
What exactly transpired between this couple is highly complex and
speculative. Apparently, they had not sufficiently reconstructed their
blaming philosophies nor acquired adequate interpersonal, coping skills
to handle each other's destructive provocations.
Appropriateness of a Conjoint Session

The advantage of presenting this particular case, which embraces
failure unabashedly, is that it abounds with opportunities for rich hypo-
thetical debate. It is posited that, given the anger-inducing ideas of the
husband, the antagonistic stance of the wife, and the couple's pervasive
resistance to taking personal responsibility for their marital dissatisfac-
tion or constructive experimentation, conjoint therapy had a high proba-
bility of failing. It seems possible, however, given the minor advances
accomplished individually, that additional individual sessions could
have reaped more productive benefits.
Individual therapy affords an opportunity analogous to a parallel or
good faith contract (Weiss, Birchler, & Vincent, 1974), whereas conjoint
therapy is encumbered with many of the disadvantages of a quid pro
quo agreement (Lederer & Jackson, 1968). That is, in the former, a per-
son's individual decision to change his or her behavior is independent
rather than functionally related to the spouse's actions, thereby obscur-
ing competitive comparisons of effort between partners. The Smiths'
hypervigilance of each other's behavior, rather than their own, may
have weakened their ability to tolerate regressions in their spouse.
Summary
The pivotal variables contributing to the failure of this couple's ther-
apy were not investigated systematically. It seems reasonable, however,
to identify the following components: (1) The couple's dysfunctional
beliefs were deeply ingrained. (2) Some of the maladaptive beliefs cre-
ated an aversion to collaborating. (3) The couple had a history of nega-
tive experiences that fortified their pessimism. (4) At least one member
was significantly depressed with a high tendency to personalize nega-
tive interactions and to connect his or her happiness and self-esteem
with how significant others perceived and treated him or her. (5) There
had not been enough time for the couple to learn and to rehearse inter-
personal, coping strategies to immunize them against their partner's

verbal attacks. Finally, (6) it is possible that the therapist's own dysfunc-
tional thoughts about her inability to help this couple in the agreed upon
time framework and to integrate cognitive and behavioral strategies ef-
fectively interfered with her functioning and conveyed a defeatist out-
look to the couple.
CASE 2: SUCCESSFUL INDUCTION AND ENHANCEMENT

OF A COLLABORATIVE SET
The next example illustrates a more successful induction and en-

hancement of a collaborative set in a distressed couple. First, the wife
was treated individually to develop a constructive motivational set and
attitude. Such preparatory inductions helped maximize the positive ef-
fect of subsequent conjoint sessions and increased the couple's expecta-
tion that they could effectively resolve their problems.
Jean Saunders was referred by her family internist due to an

anxious and depressed reaction to fertility problems. For two years
she and her husband, Mark, had tried unsuccessfully to conceive.
Innumerable tests showed no biological obstacle to conception.
Upon intake, Jean's ideas about her infertility were extreme and
depressogenic. She firmly believed that "it would be tragic if I
couldn't have children. It's all I ever wanted. I couldn't give Mark
what he wants." Jean not only felt disappointed; she felt decimated.
When asked to recount her husband's viewpoint, she quickly
discounted Mark's rational argument. Mark had told her that al-
though he very much wanted to have a baby, he most highly valued
his relationship with Jean. He was most concerned about the aver-
sive effect the infertility problems had had on her health and on the
marriage. Mark seemed to feel optimistic about alternative channels
of obtaining a child (e.g., adoption), and allegedly believed that they
could be happy regardless of whether they ultimately became par-
ents. Jean disqualified these remarks by presuming that Mark was
unable to express his "real" feelings. She also interpreted his
healthy attitude as artificial hope and happiness designed to relieve
pressure imposed on Jean to reproduce.
With further questioning, it became apparent that Jean vehe-
mently resented Mark. She felt deprived, hostile, and victimized
because of her infertility problem. She viewed her situation as horri-
ble and unfair and Mark as inattentive to and unsupportive of her
needs.
Several problems revolved around their sexual activity. Their
obstetrician had advised them to have intercourse only on particular
days and during specific moments. By strictly adhering to these
orders, the couple sacrified much of the spontaneity and enjoyability
COGNITIVE-BEHAVIORAL 5TRA TEGIES 139
of their previous sexual encounters. Jean became angry when Mark

seemed tired or unexcited about having sex. She thought, "He's not
interested in having a baby. If he loved me and wanted to have a
baby, he would show more enthusiasm. He doesn't appreciate how
difficult this situation is for me." On the other hand, when Mark
was enthusiastic and romantically inclined, she again felt angry:
"He expects me to enjoy this mechanistic act? He doesn't appreciate
how difficult this situation is for me!"
Dealing with Competitive Feelings Aroused when Individual

Sessions Are Recommended for Only One Spouse
The therapist decided to work with Jean on an individual basis to
undercut her resentment toward her husband and to introduce her to
the basic cognitive model of introspection and constructive thought crit-
icism. But first, it was necessary to elicit and to deal with her competitive
feelings about receiving such treatment. Jean verbalized apprehension
and anger over the meaning she imputed to exclusive individual ses-
sions-that she, rather than Mark or the infertility problem itself, was to
blame for their anxiety and deterioration of the marriage.
The therapist asked her to define the difference between blame and
responsibility. Jean stated that blame would probably lead to derogatory
feelings about herself, whereas responsibility, a nonprejorative term,
allowed for greater personal influence in a constructive manner. The
"blame" ascription had blocked her capacity for self-examination.
Since the couple could not afford separate, individual sessions and
since Jean was showing more obvious signs of distress, it seemed logical
to offer her relief first. It was pointed out that she was "making a
contest" between herself and Mark rather than questioning what she
could do for herself that would be in her own best interest. To dilute
further the apparent one-sidedness of the treatment program, the thera-
pist added that in Mark's therapy he also would be held responsible for
his portion of the experienced distress. At this point Jean seemed ea-
gerly motivated to begin individual sessions, although various degrees
of competitiveness had to be monitored continually throughout
treatment.
Individual Sessions
As an initial intervention, Jean explored how her ideas and behav-
iors thwarted rather than advanced her goals. For example, the therapist
140 jANIS LIEFF ABRAHMS
challenged her assumption that "if Mark loved me, he'd always want to
follow the doctor's orders." Playing the role of Mark, Jean was asked to
"comprehend with accuracy" or to empathize (Burns, 1980) with Mark's
perspective.
THERAPIST: I understand that there are times when you don't feel like having
sex.
JEAN (as Mark): Sometimes I get fed up with our problems.
THERAPIST: Is that because you don't care about Jean?
JEAN: That's ridiculous. I love Jean, but this has been an ordeal for both of us. I
sometimes feel pressured to perform.
THERAPIST: Is your lack of enthusiasm indicative of your disinterest in having
children?
JEAN: That's also ridiculous. Besides, much of the time, I'm the enthusiastic one.
THERAPIST: Do you think you alone have experienced unpleasantness regarding
the infertility problem?
JEAN: No. Actually, Jean is the one who has to monitor her temperature and take
multiple tests.
THERAPIST: It sounds like you do have some appreciation for what both of you
have gone through.
JEAN: I really think I do.
This empathy technique exemplifies how one spouse's maladaptive

attributions can be refuted unilaterally and expeditiously. Jean com-
posed the following statement upon seeing Mark more clearly in relation
to herself: "Sometimes Mark doesn't feel like having sex because he's
human. Like me, he has varying states of arousal. Neither he nor I is
always capable of being responsive in a flash. Even if he is unenthusias-
tic about having sex at times, I know he loves me, and I know he very
much wants to have a child." She gradually became more accepting of
her own and her spouse's limitations and worked on accurately constru-
ing their disappointing sexual interactions.
Nonetheless, Jean recurrently felt infuriated when Mark fell short of
her expectations. On one occasion, she chose to spend the day watching
him run a marathon. She then expected him to join her for dinner that
evening. Instead, he went to a pub with several friends and returned
home two hours late. Jean was livid because this event had underlying,
anger-inducing significance: "I overextend myself for him. He should
reciprocate. If he doesn't, he stinks and so does the marriage."
The therapist pursued the logic of this argument: "In what percent-
age of marriages in the United States do the spouses do for each other
exactly equally?" Jean laughed and answered, "Five percent." "And is it
reasonable and fair to evaluate your marriage only on those occasions
when Mark does not act as you had hoped?" "No," she replied, "I could
expect to be disappointed quite often with that point of view." The
therapist helped Jean to see that reciprocity is an ideal that can be ap-
proximated only through mutual trust, by making one's spouse feel
important and by being a valuable companion and friend. Again, coer-
cive and punitive recriminations obstructed rather than enhanced her
spouse's desire to reciprocate.
Jean saw no advantages to insisting that reciprocity be instantane-
ous and perfectly balanced. She could not possibly meet his expectations
nor would she want to, she would repeatedly feel let down, and possi-
bly, she could make the marriage so unrewarding that he would aban-
don her.
Seriously considering the undesirable consequences of her assaul-
tive communications, Jean returned the following week with a revised
perspective:
It's unreasonable for Mark to always provide for me the way I'd like him to.
What stinks, then, is not Mark, me, or the marriage, but my unrealistic
expectation that he must do for me exactly as I think he should. He is a free
and autonomous person. If I only love him when he obeys my rules, my love
is shallow. I can work on overcoming my deeply entrenched "should" state-
ments and on allowing Mark to love me his way (at least, some of the time).
Moreover, I have difficulty accepting the fact that it may be desirable to act
selfishly some of the time. I both resent and admire him for thinking of
himself. I sometimes wish I could do the same for myself.
Jean confronted her apparent "love addiction" (Ellis & Harper,

1975). She had an overriding and excessive need to be shown how
important she was to Mark and how loved she was by him. Otherwise,
she felt misunderstood, unappreciated, and inferior. She admitted that
she often felt jealous of Mark's relationship with his mother and hurt
when friends excluded her. By monitoring her automatic thoughts, she
proved to herself that she often invoked the issue of love indiscriminate-
ly.
Three major interventions were used to break through her preemp-
tory belief that she needed Mark to love her more or better. First, the
therapist inquired, "How many times would Mark have to tell you
forcefully and convincingly that he utterly despised you before you
believed him?" Jean answered, "Not more than once." The therapist
persisted, "And how many times does he have to tell you he loves you
before you believe him?" Jean understood that as long as she needed
constant reassurance, she would never feel confident about her relation-
ship.
To explore her silent assumptions, the therapist then asked, "If
Mark, in fact, did not love you as much as you would like, why would
this be upsetting to you?" Jean realized that she attached her capacity for
pleasure to his demonstrations of love. Using the Pleasure Predicting
Form (Beck et al., 1979), she soon produced evidence that refuted this
mistaken belief.
Next, the therapist used a particular example to demonstrate how
Jean mindread Mark's intentions, inferring lack of love from his behav-
ior. Jean reported feeling jealous and resentful of Mark's mother because
she assumed Mark loved his mother more than he loved her (90% be-
lieved). She then explored other, equally plausible, less personally hurt-
ful explanations as to why he sometimes inconvenienced himself for his
mother (against Jean's wishes): (1) He felt obligated to his mother (90% );
(2) he believed Jean would be more forgiving than his mother (80% ); (3)
he wanted to act as he did because it seemed convenient or reasonable to
him (90%); or, more generally, (4) Mark could not resist his mother's
demands (100% ). Her belief in the initial hypothesis immediately
dropped to 5%. She realized that because she had a bottomless, self-
destructive need for love, she tended to yoke Mark's regard for his
mother to his disregard for her. When future incidents occurred, she
tried to employ corrective thinking measures by reminding herself of his
assertiveness deficiency with his mother, his right to act in ways that
were discordant with her wishes, and her tendency to question his love
inappropriately.
Conjoint Sessions
Restructuring the Couple's "Happiness Equals Parenthood" Formula

By the first conjoint session, Mark had read enough cognitive-be-
havioral literature to grasp its basic tenets. He empathically reiterated
his adaptive view of their infertility problem, stating that they both had
been gravely upset and terribly inconvenienced by sexual pressures. But
he challenged Jean's idea that he would consider her a bad wife if she
did not provide him with a child. In a poignant and loving tone of voice,
he reconfirmed an invaluable point that, perhaps, no therapist could
deliver so convincingly: "I'd like to regain our happiness, Jean. We've
got a strong marriage. I married you for you, not for what you might
give me at some future date."
In an attempt to free Mark from his rational role and to ally the
spouses with each other, the therapist encouraged Mark to express any
doubts or disturbances that sometimes crossed his mind. Both partners
CoGNITIVE-BEHAVIORAL STRATEGIES 143
admitted that they occasionally still believed that they could not be
"truly" happy without a baby. A variety of techniques were used to
expose logical inconsistencies between the ostensible validity of this idea
and the reality of their experiences.
Over the next four weeks, the couple sensitized themselves to en-
joyment by recording events that they experienced at a 60% or higher
level of pleasure. They were instructed to monitor closely their positive
moods and to transcribe at least three pleasurable experiences a day that
were unrelated to parenting and that represented a broad sampling of
times when they were alone, with their spouse, or with other people.
The couple received a copy of the Pleasant Events Schedule (Lewinsohn,
Munoz, Youngren, & Zeiss, 1978) to augment their awareness of every-
day pleasures that inadvertently might be discounted or overlooked.
Each spouse then shared with his or her partner the most pleasur-
able moments of the week. Jean noted such items as "going to bed
early" (100% ), "feeling competent at school" (90% ), and "having dinner
with Mark" (90% ). Mark's responses included "taking a walk with Jean"
(90% ), "running" (90% ), and "visiting friends" (90% ). Here, couples
therapy proved particularly valuable because both spouses were re-
minded of highly enjoyable events that the other had forgotten.
The therapist elicited the internal dialogue that accompanied sever-
al of the pleasurable events. The couple's positive mood was captured in
thoughts that were completely unrelated to having a child (e.g., while
jogging: "My body is working well today. The air smells great."). When
asked to reconcile the results of the experiment with their initial idea,
the couple drew the following reformulations: "Mark and I experience
high levels of pleasure that are unrelated to having a baby."
Jean seemed perplexed and resistant. Believing the above restate-
ment only 70%, she disqualified its validity by retorting, "We can be
somewhat happy-I can't disregard the results of the experiment-but I
don't experience real'highs.'" Jean, an elementary school teacher, then
was asked, "If you were grading an exam and divided final scores into
high, medium, and low categories, what would constitute a 'high' range
of scores on a scale of 0-100?" Jean replied, "85-100%." "And looking
at your pleasure sheet," the therapist pursued, "have you had any
experiences that fall into that category?" Jean realized how she had
disqualified the positive evidence that rendered her predominant view
inaccurate. The therapist had Jean read about disqualification errors to
strengthen further her comprehension of corrective thinking.
Due to the nature of her prevailing belief, Jean predictably admitted
that even in the face of concrete evidence that clearly did not confirm her
existing belief, "I don't buy it emotionally." The therapist then ex-
plained emotional reasoning, or drawing conclusions based on the way

one feels. In effect, Jean was thinking, "I feel doubtful about the legit-
imacy of the restructured statement; therefore, it must be wrong."
Jean still believed that the key to her misery was her childless state.
The therapist zeroed in on how that destructive belief created her dis-
tress, rather than the condition itself. An analogous situation was pre-
sented to help Jean restore her objectivity.
A woman once believed that she could not be happy as long as she was
unmarried. Using the Pleasure Predicting Form, she tested out this hypoth-
esis by going to a movie alone. She had expected a ten percent pleasure level
and had recorded an actual ten percent pleasure level. She, therefore,
thought she had proven her point. In the next therapy session, the therapist
asked her to describe the movie. While doing so, the woman became quite
animated and amused. The therapist again inquired about her low enjoy-
ment level. In a moment of reevaluation, the woman admitted, "Actually, I
loved the movie itself" (90% believed), "but as I was leaving the theater, I
realized that I was the only person there who was alone. I thought I must be
unattractive, inferior, and generally undesirable. My mood plummetted."
The therapist then asked Jean what made the woman miserable.
She responded, "Being alone!" Once again, Jean selectively com-
prehended this event in a manner consistent with her own self-defeat-
ing, information-processing schema. The therapist persisted with an-
other story.
Another woman went to the theater alone. She also found the movie highly
enjoyable. But as she was leaving, she thought, "I really respect myself for
seeking pleasures alone. I feel I have a lot of courage. It's refreshing and
freeing to know I don't need other people to make me happy."
Eventually, Jean realized that it was the idiosyncratic meaning that

she ascribed to being alone or to having a child that dealt the devastating
blow to an undesirable situation.
Next, the therapist helped the couple understand how negative
beliefs perpetuate themselves by creating a self-fulfilling prophecy. Jean
had menstruated on New Year's Eve, an event that precipitated a severe
mood drop in both partners. She had wanted to avoid that evening's
party but managed to go. From the pleasure sheets, the therapist dis-
covered that she had had a wonderful time.
Figure 1 shows how avoidance of potentially gratifying situations
could buttress a faulty belief system. The therapist asked Jean why it
would have been contraindicated for her to have gone to bed. Jean
discerned that she probably would have felt worse and that she might
have reinforced her basic premise that she was miserable because she
could not have a child. Jean then was asked to write rational disputa-
DYSFUNCTIONAL BELl EFS POTENTIAL

BEHAVIORS
If I go to the party, I'll spoil it for Anxious Stay home,

the other people. go to bed early,
I would feel like a spectator. cry self to sleep
When I feel like this, I can't relate
to other people well. Inadequate
Other people can act and feel goofy
and can have a great time. I can't.
I can't be happy until I have
a baby. Envious,
depressed
FrcuRE 1. Dysfunctional belief cycle.
tions based on the reality of her experience that evening. She stated
unequivocally, "People enjoyed my company. (One person asked me to
stay past 2 A.M.) I related well to people. A couple of times I felt and
acted goofy. The party was really fun." The credibility of Jean's dys-
phoric beliefs were shaken, again.
Another angle to the crux of the problem underlying Jean's re-
sistance to change fortuitously was exposed when she began to have
negative feelings toward her husband in the therapy session. She ques-
tioned how Mark could have wept bitterly when she had menstruated
on New Year's Eve, yet believed he could be happy without a child. To
Jean, giving up the misery was equated with giving up the desire to
have a child. In essence, she was not free to enjoy her life without
attaching a negative valence to that attitude.
The therapist inquired, "Do you see any errors in your belief, 'If I
have fun today, I am no longer interested in having a child'?" Irra-
tionally, Jean reasoned that if Mark could be happy without a child, then
only several equally upsetting explanations existed for his behavior on
New Year's: (1) Mark had been lying about how much he wanted to
have a baby; (2) his display of unhappiness was ingenuine, a provision
of false sympathy, or (3) he only wanted a baby to appease her. Jean
simply could not fathom how Mark could have despaired over not hav-
ing a child, yet see their present lives as satisfying.
Jean separated her beliefs into two analyzable statements. (1) "Mark
is genuinely sad that we can't have a baby this month." (2) "If we don't
conceive this month, Mark is committed to making his experiences high-
ly gratifying." Jean agreed that these two ideas could coexist. One could
be quite saddened about not procreating and know that one's life was
rich in delightful moments. Jean also understood that people upset

themselves to different degrees, not because of how absolutely impor-
tant a particular issue is to them, but how important they make that
issue relative to other areas of their life. Jean concluded, "I can see that it
might be possible to give up the distress without giving up the desire to
have a child." Ellis and Harper (1975) assert this point when they sug-
gest giving up the desperate, neurotic component of an idea while re-
taining one's desire to attain a particular goal. The therapist corrobo-
rated that committing oneself to a vitally absorbing and enjoyable
existence was exquisitely compatible with wanting to have a child. Both
were life affirming.
Furthermore, Jean explored the advantages and disadvantages of
believing, "I must be miserable as long as I'm childless." She realized
that the advantages were few and antigrowth in nature. She could con-
tinue to blame her misery on her situation and not have to rethink her
maladaptive ideas. The disadvantages were more weighty including
burdening her prospective child with her happiness, thereby creating
excessive power for and pressure on that child, and contaminating her
present life. Given the uselessness and invalidity of her belief, Jean
began to appreciate her marriage with new awareness.
Balancing the "Good" and "Bad" Partner
Competitive feelings, again, were being stirred up in Jean. She had

stated earlier that she resented viewing the infertility problem as mainly
her problem. And much of the discussion had thus far centered on
Jean's inability to dispel her obsessive focus. To defuse potential polar-
ization between the marital partners, a rationale was offered to help the
couple accept the differential between their capacities to digest the new-
ly presented "happiness in spite of parenthood" formula. First, the
therapist elicited their ideas about Jean's "resistance." Jean said she
might be too stupid to change, and Mark said she might not want to
change. The therapist then presented a more reassuring, less patholog-
ical explanation: "It is the nature of a prevailing belief to seem eminently
real and to pop reflexively into one's head regardless of one's motivation
to change." Pointing to the green carpet in the conference room, the
therapist observed,
All your life you've [Jean] thought that this carpet is red. Now I'm telling you
that it might help you to see it as green. This mix-up is confusing you. Don't
expect yourself to accept this new hypothesis so easily. People don't change
so instantaneously. I understand completely that what I am telling you today
is difficult to digest. But I also believe that you owe it to yourself to consider
it.
To reduce further the couple's negative judgments regarding Jean's

rejection of the corrective model, the therapist pointed to Jean's past
experiences over which she had no control. The primary focus of her
upbringing had been her family, whereas Mark's parents had suffered
serious disappointment in their children (Mark's brothers). This infor-
mation was used to clarify how she might have learned to magnify the
importance of having children through repeated parental messages.
Mark, fortunately, reinforced this point by facetiously adding, "Al-
though I am the exception, of course, my parents never made me believe
that children were the lifeline of their relationship."
These interventions helped create a therapeutic climate of accep-
tance in which each individual was granted the freedom to experience
and to express his or her negativity. To push too hard or too soon for
change would have forced Jean into a cognitively repugnant position.
She either might have viewed herself with reproach or rejected the
therapy, therapist, and her spouse for not being sensitive to her experi-
ence.
Dealing with the Couple's Sexual Problems

Cognitive-behavioral interventions were aimed at mitigating the
couple's sexual frustration caused by a rigidly prescribed medical reg-
imen. The Saunders also held several ideas about their sexual activity
that significantly deflated its enjoyability while engendering pervasive
feelings of inadequacy.
The couple was asked to record their dysfunctional thoughts during
their next sexual encounter. Both believed that they always should have
high levels of pleasure. They should never feel pressured or annoyed,
but rather romantic and highly aroused. When questioned about the
usefulness and validity of these "should" statements, it became evident
that their underlying belief was somewhat superstitious: If the baby
were conceived under less than optimal conditions, they would have an
irreversibly negative feeling toward the child. The Saunders recalled
friends who never forgot the unpleasantness of the evening during
which successful fertilization took place. That experience, however, in
no way lessened their love for their baby.
The therapist bolstered this point by asking, "In a child's lifetime,
what percentage of pleasure is derived from the moment of conception
versus the growth and development of the child?" The couple laughed
and answered, "You're right. It's minor." They had magnified the im-
portance of that moment and inadvertently imposed unrealistic pressure
on themselves.
The couple also revised their "should" statements to reflect ideal
circumstances "that can only be approximated." For instance, Jean said,
"Instead of expecting that you should always be interested in sex at the
prescribed time, it would be helpful if we both tried to be more accom-
modating to each other's moods." Mark saw that it was impossible to
feel highly aroused at all times, especially with sex programmed accord-
ing to day rather than physiological response.
As revealed earlier, both partners had equated their interest in mak-
ing a child with their interest in having a child. Thus a spouse's reluc-
tance to have intercourse was interpreted as disinterest in parenting.
The couple worked together to compose a realistic attitude (which they
reported as 95% believable) that disconnected their level of sexual
arousal at any given moment from their long-standing desire to have a
child.
Mark also had exaggerated the meaning of Jean's having an orgasm.
The therapist asked him, "Why should Jean have an orgasm? What does
it mean to you about you and about her if she does not?" Mark's perfor-
mance anxiety was rooted in his assumptions that (1) he was inadequate
as a lover and husband if Jean did not have an orgasm and (2) Jean could
not enjoy herself without an orgasm. The personalization error in the
first conclusion was challenged by having the couple generate alterna-
tive reasons for Jean's inorgasmic state-reasons that had nothing to do
with Mark. In this exercise, Jean was extremely helpful in explaining
what thoughts sometimes interfered with her arousability (e.g., "Here
we go again. It's useless.") Jean also convinced Mark that pleasure was
not ali-or-nothing and that orgasm was not the sole route to relatively
high levels of sexual pleasure. Thus by checking out his mistaken prem-
ises, Mark gained a more realistic and salutary perspective. He seemed
to accept fully her refutations and reported great relief in their future,
coital interactions.
"Antithwarting" interventions (Burns, 1980) also were employed.
That is, instead of becoming angry, defensive, or sullen about their
partner's sexual response, the couple learned to communicate more
adaptively, affectionately, and empathically. Through role playing, they
learned to accept each other's limitations and mutual frustrations rather
than to impose further obstacles by trying to make the other feel guilty
or inadequate.
By sharing each other's automatic thoughts, the Saunders realized
that they both felt pressured and inconvenienced. Jean often thought, "I
know this is important, but I don't want to have sex now. He acts as if
we should be having a romantic time." Mark often thought, "This is
such a pain in the ass. I hope she doesn't get too upset. Come on, Jean.
Have an orgasm. It's important." The couple became partners rather
than adversaries when they saw the problem through their spouse's
eyes.
Following these cognitive changes, a behavior exchange program
was implemented. The therapist asked each partner to write down three
activities that he or she would like his or her spouse to do more of, being
positive and specific (Stuart, 1980). After some negotiating, the couple
traded behaviors, agreeing to try to act as the other wished. The main
purpose was to increase their sexual satisfaction. For instance, Jean
agreed to act "as if" she felt romantic, ignoring her "true" feelings.
Mark agreed to approach Jean in a variety of locations around the house
rather than just in the bedroom. One week later, the couple reported
that their lovemaking had become exceedingly satisfying, even while
adhering to the doctor's temperature-controlled recommendations. By
the end of the week when the novelty had worn off, they still managed
to humor each other and not to magnify the "intolerability" of the
situation.
Summary
The combination of cognitive and behavioral techniques, unfolded

with proper timing in individual and conjoint sessions, thus helped to
rectify the childless couple's dysfunctional expectations about their abil-
ity to be happy individually and jointly, as well as to have satisfying
sexual interactions. It is posited that the couple's adoption of a more
positive, team-like attitude was crucial in facilitating their willingness to
engage in subsequent, constructive behavioral experiments--experi-
ments that served to expand their actual capacity for happiness.
IDENTIFYING AND RESTRUCTURING MALADAPTIVE fORMULAS

REGARDING RELATIONSHIPS
By restructuring faulty relationship expectations or "should" state-

ments, an individual may experience relief without needing to modify
his or her spouse's undesirable behavior.
Examples of dysfunctional relationship formulas include: "Once the
romance is gone, the relationship is worthless." "If my spouse is less
motivated than I am in therapy, we have no chance of improving." "I'll

be put in a demeaning position if I initiate positive action first." And, "If
my spouse cared about me, X." This last idea could be completed "Yith
any number of unwarranted conclusions. Several deleterious relation-
ship expectations will be discussed below.
One patient was irritated that her husband was not more affection-
ate. In actuality, she exaggerated how little she got out of the relation-
ship and often discounted those times when her husband did act
lovingly. Her anger sprang from several preemptive assumptions (John-
son, 1977): "My ideas about how you should act are right. You have free
will. You should be able and willing to change your behavior to meet my
expectations."
These assumptions obviously are presumptuous because there is no
written, universal rule as to the degree of affection that one should show.
Moreover, given different upbringings, the marital partners experienced
the display of public affection differently. The wife relished it; the hus-
band was embarrassed by it. One placed a positive, the other a negative
value on the behavior. The husband's behaviors and emotional reactions
were dictated by his value judgments and conditioned responses. He
could not easily and quickly modify his behavior and, in fact, was not
highly motivated to do so, even though he loved his wife. What is
considered excessive or deficient about a behavior thus frequently is
arbitrary and subjective. Through examination and correction of the
couple's biased expectations, a more positive view of the marriage was
developed independent of changes made in the partners' affectionate
initiations.
CASE 3: THE CONTROLLING EFFECT OF A

MALADAPTIVE RELATIONSHIP FORMULA
The following case study exemplifies how a maladaptive for-

mula critically instigated interpersonal conflict. Peter and Lois Reed
entered therapy because after 16 years of marriage, the husband "no
longer loved his wife." They were both greatly disturbed by this
belief, partly because they were not sure whether to continue living
together or to begin divorce proceedings. They had two children
whom they both loved and did not want to disrupt unnecessarily.
They also seemed interested in making the marriage work, if possi-
ble. The husband had sought medical advice, hoping for a physical
explanation to account for his waning romantic feeling for his wife.
Medical tests proved negative. He then thought he might be de-
pressed and sought psychological counseling.
Thereapeutic interventions zeroed in on the couple's de-
leterious cognitions and behaviors. The therapist asked Peter to de-
CoGNITIVE-BEHAVIORAL STRATEGIES 151
fine the meaning of love. He replied vaguely, "A romantic, tingling,

swept up feeling; security; clear assurance that this is the person
with whom you want to spend the rest of your life; an overwhelm-
ing desire to be with someone."
To uncover underlying silent assumptions, the therapist then
asked, "What does it mean to you about yourself, your wife, and
your relationship in general that you no longer love your wife ac-
cording to your definition?" Peter answered, "Because I no longer
love my wife, but can't offer any valid reasons why, (A) something
must be wrong with me; (B) Lois can't be happy in the marriage; and
(C) the marriage is irremediable."
Lois made similar assumptions. She equated a genuine ex-
pression of love with a lifetime guarantee of a viable relationship.
Emotional reasoning insidiously affected her perceptions: "If I don't
feel loved (and I can't feel loved if Peter doesn't tell me he loves me),
the marriage is rotten, my husband is rotten, and I've failed."
Lois also operated under the misassumption that her husband's
insecurity created her insecurity. She was shown that it was, in fact,
her own questioning about her lovability and capacity for experienc-
ing pleasure without Peter's professed love that created her insecuri-
ty. Lois was trained to use a wrist clicker to catch her dysfunctional
thoughts. She readily noticed the connection between her insecure
ideas and her mood drops. Her husband's behavior merely contrib-
uted to but did not determine her affective response.
Spurred by their exacting relationship expectations, the couple
interacted in severely punitive ways. Peter stopped making love to
Lois because he believed his sexual advances would be misin-
terpreted as an admission of love. Reasoning that such action might
confuse Lois and create false hope, he made a "humanitarian" deci-
sion to remain withdrawn until he was certain of his commitment.
Lois, feeling apprehensive and threatened, exhorted him to make
love to her to prove his heterosexuality. On a practical level, their
actions further alienated each other.
Individual Sessions
Several individual sessions were spent discussing the couple's crip-
pling ideas. Lois explored her fear of being divorced, contemplating
how she could manage if this undesirable event became a reality. She
earnestly believed: "If Peter leaves me, I wouldn't be able to cope. It
would be evidence that I was defective. I would be devastated." But by
reviewing her capabilities objectively, she realized that independent of
Peter, she had made most of the major decisions regarding the children,
had successfully run the household, and had functioned admirably in

part-time jobs that supplemented her income. She gradually felt more
confident of her ability to survive and less desperately in need of Peter's
love.
In learning to reattribute more accurately Peter's loss of faith in the
relationship, Lois realized that it was their definition of love and its
alleged importance, not her inherent desirability as a wife, that had
precipitated much of their uneasiness. Consequently, she became more
tolerant of his uncertainty, less hateful of him, and less self-flagellating.
She began to function more joyfully, continuing to hope that Peter
would choose to remain in the marriage.
In Peter's individual sessions, he began to defuse his distress by
first realizing that he had acceptable options. In order to assess real-
istically his interest in preserving the marriage, he had to feel free to
terminate it without loathing himself. He confronted his double stan-
dard, that is, a nonjudgmental attitude toward divorced friends, yet
condemnation of himself. He also realized that his children might fare
better with divorced parents than with ones who resentfully protected
the marriage for the children's sake. Paradoxically, by dissolving all
coercion to commit himself to the marriage, he reduced his resistance
and increased his desire to improve his marital situation.
Conjoint Sessions
Peter had remained withdrawn because he believed "it was better
for Lois," and "to act romantically, I must feel romantic." He began to
treat these beliefs as testable hypotheses, agreeing to initiate lovemaking
again on a regular basis (which was operationalized in greater detail).
Lois understood the nature of the experiment and agreed not to perceive
his overtures as a guarantee of security, but as an attempt to develop the
strengths of the relationship. She also agreed not to evoke the question
of love for two months, after which time the effects of the therapy would
be reviewed.
The therapist delved further into the couple's assumptions about
love. "Why must you 'love' or 'be loved' to be gratified in the mar-
riage?" "What percentage of couples in the United States today do you
think experience gratification to the extent that you expect to?" The
therapist asked Peter, "How much have you loved Lois in the last two
weeks?" Peter replied, "50 to 70% ."The therapist continued, "And how
much have you liked Lois?" "75 to 100%," Peter answered. The thera-
pist then inquired, "And how much would you have to like Lois in
order to sustain comfortably the marriage?" This rational dialogue

helped the couple to operationalize the viability of their relationship
according to observable and testable indicators, for example, pleasure
derived from mutually enjoyable activities and the willingness and abil-
ity to problem-solve satisfactorily. By focusing on specific, positive, be-
havior changes and concrete strengths of the marriage, the Reeds disen-
gaged from vacuous debates about the relationship's worth.
Pleasure predicting was implemented by scheduling specific, po-
tentially enjoyable, joint activities. The Reeds rated as highly pleasur-
able such events as going to a restaurant, taking the kids to the beach,
watching a movie, doing yard work, and furniture shopping. They also
independently rated their level of gratification in the marriage on a
weekly basis. These levels consistently exceeded the 75% mark and
chipped away at Peter's doubt.
The couple conducted a comparative study, asking two very close,
seemingly happily married friends to rate their approximate range of
marital gratification over each of the past five years. Their scores varied
widely. The couple observed that they simplistically had viewed love
and happiness as full or empty when, in fact, even in the best of mar-
riages, there are bound to be arid spells.
Thus Peter and Lois identified and challenged the cognitive base
that had eroded their trust in one another and produced noxious marital
interactions while experimenting with more constructive behaviors.
They concluded that things were not as bad as they had first thought,
that they had proven their capacity to enjoy each other, and that the
value of the relationship could not be subsumed under one nebulous,
omnipresent sensation called love. The Reeds successfully terminated
therapy following several communication skill training sessions.
Summary
This case presentation illustrates the sapping effect that faulty rela-
tionship expectations can have on a couple's adaptive functioning. Ef-
fective challenge of these cognitions again seemed to foster positive
attitudinal changes that potentiated new, constructive actions.
CoNCLUSION
Which, when, and with whom specific treatment strategies should

be employed are questions that need to be investigated as an interper-
sonal model of cognitive-behavioral therapy is developed. Several issues

will have to be addressed: (1) When are individual versus conjoint ses-
sions most efficacious? (2) What is the unique value of cognitive strat-
egies (designed to identify and challenge the belief system of partners)
versus behavior exchange strategies (which focus more concretely on
the modification and exchange of behaviors)? (3) How should cognitive
and behavioral interventions be sequenced relative to each other to max-
imize their effects? (4) To what extent do cognitive and behavioral strat-
egies facilitate the induction and enhancement of a collaborative set
within partners? (5) In what way are the following factors relevant (a)
the intransigency of each partner's maladaptive beliefs, (b) the per-
vasiveness of each partner's distress at the time of therapy, and (c) the
premorbid constitution of each marital partner and the marriage itself ?
Whereas Jacobson and Margolin (1979) acknowledge that "behavior
therapists might at times find a cognitive emphasis advantageous" (p.
149), the specifics remain undelineated. Future research may demon-
strate empirically that the potency and scope of behavior therapy tech-
niques are incrementally enhanced when key, underlying cognitions are
explicitly treated. Effective cognitive revision seems to potentiate a col-
laborative set and new, constructive actions (Stuart, 1980). But a certified
intermarriage of reconstructed attitudes and behaviors has yet to be
arranged in any systematic fashion.
REFERENCES
Abrahms, J. L. Inducing a collaborative set in distressed couples: Nonspecific therapist-patient

issues in cognitive therapy. Paper presented at the annual meeting of the Association for
the Advancement of Behavior Therapy, Los Angeles, November 1982.
Beck, A. T. Cognitive aspects of marital interactions. Paper presented at the annual meeting of
the Association for the Advancement of Behavior Therapy, New York, November
1980.
Guilford, 1979.
Burns, D. D. Feeling good: The new mood therapy. New York: Morrow, 1980.
Ellis, A., & Harper, R. A new guide to rational living. North Hollywood, Calif.: Wilshire,
1975.
Epstein, N. Cognitive therapy with couples. American Journal of Family Therapy, 1982, 10 (1),
5-16.
Jacobson, N. S., & Margolin, G. Marital therapy: Strategies based on social/earning and behavior
exchange principles. New York: Brunner/Mazel, 1979.
Johnson, S. M. First person singular: Living the good life alone. New York: Lippincott, 1977.
Lederer, W. J., & Jackson, D. D. Mirages of marriage. New York: Norton, 1968.
Lewinsohn, P.M., Munoz, R. G., Youngren, M.A., & Zeiss, A.M. Control your depression.
Englewood Cliffs, N.J.: Prentice-Hall, 1978.
Stein, J. (Ed.). The random house dictionary of the english language. New York: Random House,
1966.
Stuart, R. B. Helping couples change: A social/earning approach to marital therapy. New York:
Guilford, 1980.
Weiss, R. L., Birchler, G. R., & Vincent, J.P. Contractual models for negotiation training in
marital dyads. Journal of Marriage and the Family, 1974, 36, 321-331.
8
Cognitive Therapy zn Groups
with Alcoholics
MEYER D. GLANTZ AND WILLIAM McCouRT
Alcoholics are a notoriously difficult population to treat. Typically, they

seek treatment after interpersonal support systems, and economic and
employment functioning have been severely disrupted or destroyed,
and are, at best, poor candidates for psychotherapy. Their passive de-
pendent personality characteristics and their abstraction-impaired cog-
nitive functioning make them less amenable to most traditional ther-
apeutic interventions. Relapses often involve extended periods of use of
an addictive substance that removes the patient from even the pos-
sibility of therapeutic contacts; furthermore, relapses often result in the
additional deterioration of the drinkers' circumstances and the destruc-
tion of resources necessary for the control of the drinking. Alcohol pro-
vides an immediate gratification and the ingestion of even a small
amount of alcohol disrupts or inhibits exactly those cognitive functions
that are necessary to exercise the self-control necessary to prevent fur-
ther drinking and eventual inebriation. In addition, alcohol distorts the
inebriate's self-perception and diminishes or even obliterates his or her
memory of the period of drunkenness. Further, the use of alcohol is
generally socially acceptable and it is a visible often encouraged behavior
in many social settings. Despite these discouraging factors, however, a
cognitively oriented intervention designed specifically for alcoholics can
be successful. Important to this approach is some understanding of the
personality and cognitive characteristics of alcoholics.
MEYER D. GLANTZ • National Institute on Drug Abuse, Division of Clinical Research, 5600
Fishers Lane, Rockville, Maryland 20857. WILLIAM McCouRT • Southwood Hospital,
Norfolk, Massachusetts 02056. The development and practice of the therapy described
here was done at the Center for Problem Drinking, Veterans Administration Outpatient
Clinic, Boston, Massachusetts and was supported by the V. A. Medical Research Service.
157
158 MEYER D. GLANTZ AND WILLIAM McCouRT
PERSONALITY CHARACTERISTICS
Although there is a consensus that there is not a single or unique

"alcoholic personality," and no single specific personality characteristic
has been observed universally in alcoholics (Tarter, 1975b; Stein,
Rozynko, & Puch, 1971) there are a number of traits that many alco-
holologists have come to associate with alcoholism. Based on his exten-
sive review of the research literature, Cox (1979) concluded that the most
salient characteristics of alcoholics are their passivity and their depen-
dency. Catanzaro (1967) described 13 frequently observed and com-
monly attributed characteristics: low frustration capacity, grandiosity,
anxiety, guilt, perfectionism, emotional immaturity, difficulties with au-
thority, sex role confusion, poor anger modulation, excessive dependen-
cy, low self-esteem, feelings of isolation, and compulsiveness.
Although there is contradictory evidence regarding whether alco-
holics have a generally good or poor opinion of themselves (Neuringer
& Clopton, 1976), they usually are assumed to have a low self-concept.
Berg (1971) found that alcoholics had a lower self-concept than normals
and that, after drinking, the alcoholics' self-concept improved while the
normals' self-concept worsened. Vannicelli (1972) found that alcoholics
know less about their drunk selves than about their sober selves. Alco-
holics demonstrate a greater than normal discrepancy between their
perceptions of themselves and their ideal selves (Berg, 1971). They typ-
ically report themselves to be depressed (Gibson & Becker, 1973) and
anxious (Smith & Layden, 1972) and they generally have been found to
demonstrate an external locus of control (Rohsenow & O'Leary, 1978).
McCelland and his associates (1972) report that alcoholics score at high
levels on the n-power motivation scale and at low levels on the Activity
Inhibition measure. Lisansky (1967), drawing on Halper's (1946) work,
suggests that "alcoholism prone persons have not developed the usual
neurotic mechanisms of defense against threat, at least not to an extent
which makes such mechanisms effective" (p. 7).
COGNITIVE CHARACTERISTICS
In terms of cognitive functioning, a few factors commonly are

agreed on. Alcoholics do not appear to exhibit intellectual decrement as
measured by standard tests of intelligence; they frequently have been
tested as functioning within the average to superior range on such tests
as the WAIS and Wechsler-Bellevue scales (see reviews by Kleinknecht
& Goldstein, 1972; Tarter, 1976, 1975a). There is a fair amount of evi-
COGNITIVE THERAPY IN GROUPS WITH ALCOHOLICS 159
dence of deficit on some measures of abstracting ability and the ability to

process environmental input requiring conceptualization, integration,
and transformation of disparate elements in the perceptual field (Tarter,
1975a, 1976) and alcoholics fairly consistently have scored as highly field
dependent on a number of field orientation measures (Goldstein, 1976;
Tarter, 1976).
In a study investigating male alcoholics' conceptualizations of situa-
tions, Glantz and Burr (1981) found that when construing events that
cannot be classified easily and clearly, alcoholics, as compared to nor-
mals, are more likely to continue to attempt to categorize these events in
terms of the qualities that they typically employ even if they are inap-
propriate, rather than develop new more appropriate categories. In ad-
dition, they demonstrated a lesser tendency to discriminate between a
range of events and the attribution of any given quality was more likely
to be followed automatically by the attribution of other particular
qualities even in the presence of neutral or contradictory evidence. Al-
though the normals most commonly categorized situations in terms of
affiliative qualities, the alcoholics most commonly categorized them in
terms of positive or negative emotions and they seemed to have avail-
able fewer evaluative categorizations that are necessary to indicate the
desirability of actions, events, and changes.
A CoGNITIVE MoDEL OF ALCOHOLISM
We view alcohol abuse as both a problem and a solution to a prob-

lem. It is obvious that alcohol abuse leads to problems, but it is less
frequently recognized that alcohol abuse is in itself an attempt at prob-
lem-solving. These problems may be emotional (e.g., anger, helpless-
ness), social (e.g., unemployment and poverty), or interpersonal (inter-
personal conflict or isolation). Alcohol may serve as a problem-solving
or coping mechanism in a number of ways. Although alcohol is phar-
macologically a central nervous system depressant, its effect depends on
a number of factors including dosage, expectation, circumstances of use,
and physical state. It may reduce anxiety or other strong emotional
states; disinhibit internal restrictions on behaviors; blur perception of
one's self, of others, or of situations; stimulate fantasies; cause uncon-
sciousness; and facilitate the forgetting of or distortion or memory of
past events. It might be used as an excuse for failure or for other un-
acceptable behaviors, as a means of escaping situations or respon-
sibilities, or as a facilitator of or a substitute for some aspect of normal
functioning. We hypothesize that the alcoholic always has been a poor

problem solver, (see, for example, the study by McCord & McCord 1960,
1962; McCord, 1972) due to his or her maladaptive thought processes.
Failing to cope by using other problem-solving approaches, he or she
turns more and more to the use of alcohol to solve problems. As alcohol
is increasingly used as a problem-solving technique, the abuser becomes
an increasingly ineffective problem solver. Faced with problems that
cannot be affected, the only option left to the abuser is to affect him or
herself, that is, his or her experience of the problem, through the use of
alcohol. It is fairly easy to see how this problem-solving approach would
lead to recurrent themes of helplessness, low self-esteem, guilt, and
many of the other personality characteristics that have been associated
with alcoholics. It has been our observation that the clients' problems
are often rooted in their conceptualizations, that there are certain con-
ceptualization patterns that are particularly common among the clients,
that these thinking patterns are "maladaptive" or "unrealistic/' and
that a corrective change in these maladaptive thinking patterns might
well lead to at least a partial resolution of the clients' problems.
It is important to consider the characteristics of the particular pa-
tient population that is to be treated. Almost all of the research cited
above was conducted with male patients and the applicability of the
findings to female alcoholics is as yet uncertain (Gomberg, 1976). Our
model of alcoholism and its treatment is based on our clinical experi-
ences with patients at the Boston VA Center for Problem Drinking. The
maladaptive thinking patterns of the patients may be described in terms
of the basic processes that underlie their conceptualization and the con-
tent themes that typically characterize their conceptualizations. Some of
these themes may become highly prominent in the thinking and conse-
quent behavior of the alcoholic and may be considered to be personality
characteristics.
Beck (1972) has proposed a model of depression in which he em-
phasizes the role of thinking in this disorder. He has described errors in
the process of thinking that are typical of depressed patients, for exam-
ple, drawing conclusions in the absence of or contrary to the available
evidence. He described how these processes can lead to a depressive
thought content, for example, "John didn't call me tonight, he doesn't
love me anymore." We feel Beck's model is relevant to the thinking of
the alcoholic even though alcoholics are a far more heterogeneous popu-
lation than depressives and their thought disorders are more difficult to
specify. However, there are some characteristic thought processes and
contents that seem to occur frequently among our patients.
The maladaptive thought processes that we have observed gener-
ally seem to involve a failure to utilize the typical parameters, range,
content, number of, and relationship between categories or attribution

classes.
We have observed in alcoholic patients the maladaptive processes
that Beck (1972, 1976) has described for depressives. These would in-
clude drawing arbitrary inferences, making dichotomous (black-white)
evaluations, and making gross overgeneralizations. We also have ob-
served a number of other maladaptive processes. Our patients fre-
quently exhibit thinking that is either global, abstract, and undifferenti-
ated or thinking that is highly narrow, concretized, and specific. Often,
patients' evaluations are emotionally dominated. Patients frequently are
unable to identify and differentiate affects or the origin or object of the
affect (e.g., "I don't know why, but I'm angry all the time at nothing in
particular"). Evaluations often are based on a single criterion, standard
or dimension, or the criteria and categories used in evaluations are not
sufficiently discriminated from each other and/ or are applied incorrectly
(e.g., sobriety may be seen as the measure of entitlement). The alco-
holics' beliefs and assumptions are often not tested or readily subject to
disconfirmation by contradictory evidence and at least some of their
attributions are likely to be unrealistic. Many patients fail to see interre-
lationships between factors in a situation and patients often demon-
strate an arbitrary and narrow focus of attention on a single aspect of a
situation or person. Partly in consequence of this, patients often are
unable to generate or consider alternatives or to change their perspective
or point of view. Of course, this is not an exhaustive list of maladaptive
processes and we do not mean to imply that these processes are con-
fined to or definitive of alcoholics. Also, no one patient exhibits all of
these processes but, rather, they consistently appear to utilize a limited
number.
The above processes lead to a number of frequently occurring mal-
adaptive themes, or thought contents, in alcoholic patient populations.
There is not, however, an invariant one-to-one relationship between
each process and each theme; any process may lead to any one or more
of the themes and conversely, any theme may be determined by any one
or more of the processes.
We have observed a number of maladaptive theme contents. Some
of our patients believe that they are totally powerless and/or victimized.
Many of our patients have either very low or (less commonly) very high
self-images, and many either overaccept or underaccept responsibility
for either good or bad outcomes. Patients' evaluations and anticipations
frequently are pervasively negative. Some patients have an overly high
or overly low feeling of entitlement. Most of our patients believe that
alcohol is the only alternative to bad feelings and problems. This list also
is not meant to be an exhaustive one, nor are these content themes
162 MEYER D. GLANTZ AND WILLIAM McCOURT
confined to or definitive of alcoholics. Again, no one patient exhibits all

of these themes but each seems to consistently demonstrate a limited
number.
Table 1 describes the more common maladaptive content themes
that we have observed, the behaviors that are often associated with
them, examples of self-statements that would characterize them, and an
example of a way in which alcohol use might serve as a means of coping
with the consequences of the maladaptive conceptualization.
We have taken one commonly occurring theme or thought content
in the life of the individual alcoholic and have analyzed it to illustrate
our hypothesized model of maladaptive thought processes and con-
tents. The patient had been abstinent for six months and suddenly be-
gan to drink. He stated, "I don't know what happened. I just found
myself in a bar and before I knew it, I had three drinks and ended up on
a drunk." The patient's memory and understanding of this event is as if
he was a passive participant in a series of accidental events.
We hypothesize that the following processes underlie the patient's
thinking: The patient experiences a negative feeling such as anxiety or
anger which he wishes to relieve by getting drunk. The desire to get
drunk arouses guilt and must be denied. The patient compromises his
desire to get drunk with its attendant guilt by selectively focusing his
attention on the thought "I'll just have one drink." This selective focus-
ing enables him to begin drinking and at the same time to deny the wish
to get drunk. "Just one drink" is an allowable indulgence, even for an
alcoholic. Failing to see the relationship between each individual drink
and the inevitable drunkenness, the first drink is experienced as "just
one drink" and not as the first on the road to intoxication. The second
drink is experienced as "just one more," as are the third, the fourth, and
all the drinks up to the point that the patient has ingested sufficient
alcohol to remove all prohibitions and concerns about drinking. The
selective focusing on the idea of having "only one drink" allows the
drinker to dissociate his intent, actions, and responsibility from the out-
come and this allows the drinker to experience and remember events in
ways that minimize his active conscious participation and responsibility.
This model of alcoholism implies that the most effective therapy
modality for alcoholics would be a cognitively-oriented therapy. This
approach presumes that therapeutic interventions must be directed at
the patient's thinking processes as well as the symptom-related behav-
iors and characteristics and that therapeutic change must be supported
by the development of effective coping skills.
Alcoholics Anonymous has long recognized the important role of
thought processes in alcoholism. "Stinking Thinking" is the catch-all
phrase applied to the various thoughts and conceptualizations alco-

holics have that reinforce and justify their drinking. AA members con-
stantly advise their fellow members to pay close attention to the way
they think and alert their members to thought patterns that often lead to
drinking. For example, a member is warned against the consequences of
indulging in thoughts of victimization and self-pity by the slogan "Poor
me, poor me, pour me a drink." Another example is the way in which
AA changes the overwhelming thought of "a life of sobriety" to the
more manageable thought of being sober "one day at a time."
Sanchez-Craig (1975, 1980) has reported the use of a cognitively-
oriented therapy with alcoholics. In her articles, she describes a treat-
ment strategy that involves: (1) the identification and analysis of drinking
episodes, (2) exposure to the drinking stimulus situation in imagination
and desensitization of unpleasant aspects, (3) generation of alternative
thoughts and coping strategies, particularly self-statements, and (4) cog-
nitive rehearsal of new coping responses. Sanchez-Craig also describes
several case studies of individuals with whom this approach has
succeeded.
Marlatt (1976, 1978, 1979) has developed a cognitive-behavioral
model of alcoholism, craving for alcohol, and relapse. Questioning the
tension-reduction hypothesis as an explanation of alcohol's reinforcing
properties, he hypothesizes that alcohol reinforces by increasing percep-
tions of personal control and efficacy. Marlatt recommends an interven-
tion strategy for use with alcoholics that combines D'Zurilla and Gold-
fried's (1971) training in problem-solving skills with the encouragement
of alternative positive activities such as meditation and physical exercise
and an inoculation-type approach to relapse prevention. Marlatt reports
that preliminary experience indicates that this skills training approach
has "utility" as one component of a multimodal behavioral approach to
relapse in problem drinking (Chaney, O'Leary, & Marlatt, 1978).
The success that Beck, Meichenbaum, and others have had in using
cognitively-oriented therapies with various patient populations, the
compatibility of the proposed model of alcoholism with the modality,
and the favorable experience that Glantz had in using cognitively ori-
ented techniques with a group of alcoholics encouraged the develop-
ment of a cognitively-oriented therapy program at the Boston Veterans
Administration Center for Problem Drinking. The program was de-
signed for small groups of alcoholic patients. Although group therapy
with alcoholics can be difficult even for experienced therapists (e.g.,
Yalom, 1974), we felt that the cognitive therapy techniques could com-
pensate for the disadvantages of a group method with alcoholics and
could benefit from the possibility of the interactions of the patients. The
TABLE 1
Common Maladaptive Conceptualization Themes of Alcoholics
Example of automatic Example of coping function

Theme Behavioral characteristics thought of alcohol use
High self-image Conceit, feeling of superiority, rejection and I'm better than they 1) Combat feelings of inferiority
conflict with others are. 2) Reduce anger when not treated as
I don't have any superior
problems.
This job is beneath
me.
Low self-image Depression, self-denigration I'm no good. 1) Tranquilize or deaden feelings
I'm worthless. 2) Distort self-image
3) Create fantasy of a better self
High power/control Unwarranted optimism and meglomania, at- I can do anything. 1) Create fantasy and feeling of power
tempt impossible It's not impossible for 2) Tranquilize when fail
me.
Low power/control Feeling helpless and hopeless, no attempts, I can't do anything. 1) Create fantasy and feeling of power
no alternatives, depression and anxiety There is nothing I can 2) Tranquilize or deaden feelings
do. 3) Provide means to control others
4) Relieve inhibitions to act
Under acceptance of Denial of responsibility, seeing self as inno- It wasn't my fault. 1) Provide excuse-"Did cause drunk"
responsibility for cent/helpless victim, blame and resent They were respon- 2) Tranquilize or deaden feelings
bad outcome others sible.
I couldn't help it.
He gets me so mad I
had to drink.
Overacceptance of re- Accept all blame It's all my fault. 1) Tranquilize or deaden feelings
sponsibility for bad I'm to blame. 2) Distort perceptions of self or situation
outcome I ruined everything. 3) Disinhibit expression of anger and
resentment
Under acceptance of Denigration of own achievements, not re- It was luck. 1) Tranquilize or deaden feelings
responsibility for ward self It's not much. 2) Create fantasy of success
good outcome I didn't really do it. 3) Disinhibit expression of pride
Low entitlement No self reward or acceptance of good I don't deserve it. 1) Tranquilize or deaden feelings
things, self denigration and depression That's too good for 2) Distort perception of situation or self
me. 3) Permit self-reward
I don't deserve better.
High entitlement Expectation of too much for little effort, I deserve better. 1) Create fantasy of distorted situation
resentment of others, angry and demand- I should have gotten 2) Tranquilize or deaden feelings
ing attitude that.
They owe it to me.
Overly negative eva!- Unwarranted pessimism, highly critical, not Nothing is any good. 1) Tranquilize or deaden feelings
uations/ enjoy available positive things, not try It won't work no mat- 2) Distort perceptions of self or situation
anticipations new things, insufficient effort, quit easily ter what I do.
Things will never be
better.
Overly positive eva!- Unwarranted optimism, not recognize or I don't need to worry. 1) Tranquilize when disappointed
uations/ anticipate problems, poor judgments, set This will set me up 2) Create fantasy of success
an tici pa tions self up for failure for life. 3) Distort perceptions of self or situations
Those problems will
work out.
Alcohol is the only Inability to confront and cope with prob- It's the only way to 1) Tranquilize or deaden feelings
solution !ems and/or negative and strong feelings handle it. 2) Disinhibit expression of emotions
(e.g., anger, anxiety, depression, What else can I do? 3) Provide means of seeking help
loneliness) It's so bad I must
drink.
therapy protocol to be described was developed and used over a three-

year period at the clinic.
COGNITIVE THERAPY FOR ALCOHOLICS
The stated goals of the group are to demonstrate the importance

that thought processes play in the lives and behavior of the members, to
demonstrate that these thought processes are subject to change, and to
demonstrate further that this change is within the patient's control. The
group attempts to identify problem areas of conceptualizations and to
work out alternative and more constructive patterns that will lead to
more desirable feelings and behaviors. Although1the topics of the group
discussions and exercises always focus on content (theme) oriented
goals, the therapists use these activities as an opportunity to attempt to
modify the patients' underlying maladaptive processes.
In addition, the therapists help the patients to develop alternative
and more successful coping and self-regulatory skills and encourage the
patients to substitute more adaptive behaviors for those that support
maladaptive conceptualizations and symptom patterns. Although the
therapy is specifically intended for alcoholics, its focus is on maladaptive
conceptualizations and behaviors, only some of which are related to
alcohol use. The use of alcohol by the group members is discussed in the
same way as their other maladaptive behaviors and unsuccessful coping
techniques. It is expected that few, if any, of the patients will be able to
develop a controlled pattern of social drinking; this is particularly true
for patients who have not established social support systems and stable
living situations and developed alternate coping techniques. For this
reason, complete abstinence from alcohol use is encouraged.
The general principles on which therapy is based and many of the
techniques that are used are drawn from established cognitive therapy
procedures. We have relied particularly on the general strategies and
techniques developed by Beck (1976, 1979) and Meichenbaum (1975,
1977; Meichenbaum & Turk, 1976) and the skills training procedures
developed by D'Zurilla and Goldfried (1971) and Novaco (1977). We
encourage psychotherapists who wish to employ the therapy protocol
for alcoholics to familiarize themselves with these works.
The therapy also relies on the development of a facilitative group
process of open interaction among the group members. This requires
skill and experience on the part of the therapists and it is recommended
that the protocol be used by therapists who have had at least some
experience with group intervention approaches.
Although the use of a group format usually implies that the patients
share the same fundamental problem and can, therefore, all be treated
with basically the same intervention, we have found that it is necessary
to develop an individual treatment plan for each patient. Although the
same intervention strategy is applied to each case, specific goals and
intervention attempts are worked out for each patient based on his
particular maladaptive coping mechanisms; his temperament, beliefs,
and social and intellectual abilities; his social and economic situation;
and the nature and history of his drinking behavior. Although patients
are screened only to exclude those demonstrating evidence of gross
organic brain dysfunction or evidence of being inappropriate for referral
to a therapy group, they are given an extensive series of tests for diag-
nostic and planning purposes. Each patient is asked to complete a Beck
Depression Inventory, a Spielberger Trait Anxiety Inventory, a Califor-
nia Psychological Inventory, a detailed problem drinking history report,
a measure of assertiveness, and a Situations Rep Test (Glantz, 1980,
1982), which provides information about the organization and content of
the subject's conceptualizations. As part of the therapy activities, the
patients also describe their beliefs about themselves, make a short pre-
sentation introducing themselves to the group, fill out a Goal Attain-
ment Scale which describes the current status of four important areas of
their lives and the goals they would like to reach in each, and give
information about themselves through the normal activities of the group
meetings. The information from these assessments is organized into a
diagnostic picture and the problems and strengths of the patients and
therapeutic goals and potential interventions are determined. This plan-
ning is then coordinated with the therapy protocol and the therapists
attempt to accomplish the scheduled tasks for each therapy session,
while at the same time taking advantage of presented opportunities to
advance the therapeutic plans developed for the individual patients.
This requires extensive preparation on the part of the therapists and
frequently is more time consuming than the group meetings them-
selves.
An example of an intervention that was planned for a particular
patient is presented below. It was determined in advance that this par-
ticular patient typically took responsibility for negative outcomes for
which he was not responsible. The most salient of his maladaptive
thought processes was his tendency toward overgeneralization. A gen-
eral strategy was selected and when the patient related to the group a
relevant incident, the therapists used the opportunity to implement the
strategy.
The patient was a 42-year-old white man, a high school gradu-

ate who had been drinking heavily for 20 years. He was separated
from his wife, whom he visited once a week. When she saw him she
frequently became upset and angrily accused him of ruining her life
and not supporting her· financially, and thereby making her misera-
ble. The patient responded with intense feelings of guilt and respon-
sibility, usually followed by his getting drunk. In discussion, he
said, "I've ruined her life. I'm a bum because I don't give hermon-
ey. I make her feel bad."
The patient's evaluation of the situation, totally dominated by his

feelings of guilt, focused solely on himself. Furthermore, he took his
wife's accusation as a statement of fact rather than opinion. In other
words, the patient accepted too much responsibility for his wife's dis-
tress. His feelings of guilt were exacerbated by an extremely critical self-
evaluation.
An attempt was made to show the patient that each person is re-
sponsible for his own moods and feelings. The patient was asked
whether he was or ever had been responsible for his wife's good moods.
He answered "no." He was then asked how he could be responsible for
the bad but not the good moods. He said he did not know. When he was
asked who was responsible for his moods, he replied that he was. A
group member asked, "If you're responsible for your moods, how come
she's not responsible for hers?" He answered, "I guess she is." He then
volunteered that even when he was making a lot of money, his wife
made the same accusations. He said that he supposed she was an angry
and depressed person before she met him. When asked whether there
was anything he could do to make her happy, he said, "No, I guess only
she can do that." 1 The patient subsequently reported that he no longer
reacted to his wife with guilt.
GROUP TREATMENT
As conducted at the VA, the groups consisted of 8 to 10 patients and

were led by two therapists. As both of the therapists in the program
were males, a female therapist at the clinic occasionally was asked to
assist in role-playing exercises. Patients attending the outpatient clinic
were offered the opportunity to participate in a cognitive-behavior ther-
apy group as part of their regular treatment program. Each group met
twice weekly for 10 weeks. Each meeting, which was videotaped, lasted
for 1Y2 hours. Most of the patients were white, unmarried, unemployed
I Thiscase study is reprinted by permission from Journal of Studies on Alcohol (1980, Vol. 41,
pp. 338-346.). Copyright Journal of Studies on Alcohol, New Brunswick, New Jersey.
men between the ages of 40 and 50. All were veterans. Most had experi-
enced the breakup of their marriage and family, and most had had
multiple arrests, blackouts, seizures, and hospitalizations for the treat-
ment of alcoholism. The typical patient lived alone and was supported
by some form of public assistance, had a history of alcohol misuse span-
ning 10 to 20 years, and had problems similar to, but more serious than,
the "heavy intake" and "binge drinking" problem drinkers described by
Cahalan and Room (1974).
Although only some patients maintain sobriety throughout the
course of the 20 group meetings, a rule is established that any patient
who comes to a meeting in an intoxicated state will not be permitted to
attend that meeting. An agreement is made with the patients that they
will attend all 20 meetings. If a patient misses three meetings or more,
he is able to continue as a group member only if the other members are
willing to allow him to continue.
COGNITIVE THERAPY PROTOCOL
Following is the therapy protocol that describes the session-by-ses-

sion treatment plan for the typical course of therapy.
Sessions 1 and 2
Goals 1. To have patients complete several exercises that will be used in
future groups and also will aid in the evaluation of the effec-
tiveness of the group
2. To introduce the patients to the group and to establish certain
expectations and conventions for the group
Each patient completes two exercises. The first is the Goal Attain-
ment Scale (GAS), for which each patient, with the help of a therapist,
defines his current status, his 5 week, 10 week, and 3 to 6 month goals in
four areas of his life: (1) residence, (2) leisure activities, (3) employ-
ment-education-skills, (4) social-interpersonal-affiliative relationships
and activities. All of the goals must be stated in specific concrete behav-
ioral terms. Our patients have great difficulty with this task; they have a
tendency to define goals in a general, amorphous fashion with little
thought of how the goals might be achieved. Goals often are far beyond
the patient's ability. Nevertheless this exercise is useful in teaching pa-
tients to think in a concrete, goal-directed, and realistic fashion about
their lives.
The second exercise is the self-presentation. During the first session
each patient is asked to prepare to give a three-minute talk about him-
self. During the second meeting, the patients go one at a time to another
room where there are three staff members. They deliver their self-pre-
sentation to the "audience" and it is recorded on videotape. This pro-
duces an objective sample of the way in which the patient presents
himself to others. Many of our patients are publicly self-denegrating and
many are unaware of the manner in which they present themselves in
social situations.
After the completion of the exercises the patients and therapists
introduce themselves and the patients are each asked to answer three
questions: (1) When were you most happy? (2) When were you most
sad? (3) How do you feel about the future? This allows the patients to
find out a little about each other and feel more comfortable with each
other and develops the expectation that the group members will share
personal and usually private information. During these sessions, the
patients also are told a little bit about the orientation and objectives of
the group and a little about the two exercises and they are given an
opportunity to discuss them.
In all of the sessions the group process is developed and used to
facilitate the tasks and goals. This helps to develop objective observation
skills, interpersonal interactions, a less egocentric focus, a feeling of
sharing and of having common experiences, a feeling of caring for oth-
ers and an opportunity to first comprehend an idea in relation to another
and then to see how that idea might apply to oneself. Patients are
encouraged to participate very actively in discussions focused on other
patients in the group and to help each other to identify, understand, and
correct maladaptive thoughts and behaviors.
The assignment for the second session is to complete the Speil-
berger State Anxiety Scale and the Beck Depression Inventory.
Sessions 3 and 4
Goals 1. To teach patients the underlying philosophy of cognitive
therapy
2. To demonstrate to patients that their concept of themselves is
not necessarily shared by the world at large, that is, there are
different ways of viewing oneself
3. To demonstrate that one's conception of oneself is only an
opinion and not a fact; to contradict the common conception,
"It's not that I think I'm a bum; it's that I am a bum"
4. To demonstrate the notion of "reality testing"
To achieve the first goal, the therapists role play a vignette. One
therapist plays the role of the other therapist's employer; he role plays
calling his secretary and asking her to send in the employee. The pur-
pose is to tell the employee that he has received a raise. The employer
instructs the secretary not to tell the employee about the raise as he
wants to surprise him. The employee comes into the employer's office in
a hostile and belligerent way and continues to be so for the remainder of
the vignette. Clients are asked to describe what they have seen. They
usually respond with the feelings that they have observed and then with
the behavior. The patients are usually unable to think of a reason for the
employee's hostility. Only with direction from the therapists are they
able to consider what possible thoughts that participant had before
entering the office. In simple schema, plausible thoughts, feelings, and
behavior of the employee in the vignette are written out on the black-
board. It is stressed repeatedly that it was the thoughts and expectations
that determined the feelings and behavior of the employee. It is further
pointed out that many other thoughts and expectations were available to
the employee and that had he chosen them, his feelings and behavior
would have been different. Lastly, it is explained that one of the major
foci for each individual member of the group will be "how he thinks,
how he can think differently, and the benefits of thinking differently."
The group is told that they will accomplish this through the use of
homework assignments and through experiences in the group. It is
important to note that a lot of time is spent in differentiating between
thoughts and feelings. Many patients seem to be unaware of their think-
ing processes, and some patients seem to have difficulty understanding
what "thoughts" are. A definition that we have found helpful for pa-
tients is that "thoughts" are self-talk or that which you say to yourself,
about yourself, or about some other subject; the self-talk sometimes may
be in the form of images instead of words.
To accomplish the second goal, group members view their vid-
eotaped self-presentation and each is asked to comment about it. Fol-
lowing their comments, they elicit opinions about the self-presentation
from other group members. Frequently, the group's opinions are at
odds with the presenter's view of the presentation and of himself.
The discussion also is directed toward the third goal of showing that
one's self-image is only an opinion and focuses on the validity of other
people's view versus one's own. This is a fundamentally important issue
with people whose concept of themselves is either above or below that
which seems realistic. A common example is the patient with poor self-
esteem who is convinced his own estimation of himself is the only true
one. Exposure to alternate points of view tends to make him doubt the
absolute conviction.
To accomplish the fourth goal, the notion of reality testing is dis-
cussed and the exercises of checking one's opinions with the videotape
recording and with other group members are used as examples. During
all sessions, patients often are asked to compare an opinion with a tape
or the group's opinion.
The assignment given at Session 4 is for each patient to write the
five most important beliefs he has about himself.
Sessions 5 and 6
Goals 1. To explore each patient's basic beliefs about himself, to show
how they agree or disagree with other people's beliefs about
him
2. To explore the relationship between the patient's basic beliefs
about himself and other aspects of his life
3. To demonstrate to patients how readily apparent their own
beliefs about themselves are and the effects this would have on
their relationship with others
4. To demonstrate and discuss responsibility avoiding
5. To explain the general model that thoughts determine feelings
that together determine behavior and to explain the rationale
and the potential benefits of cognitive restructuring
The first three goals are the object of an exercise using the "five
most important beliefs about myself" assignment. A patient is selected
and the other group members attempt to guess what the patient listed as
his beliefs about himself. Then, the group describes their own opinions
about the patient. Although the group members usually have not had
much contact with each other before the group was formed, they usually
have opinions about each other and are able to make a guess about each
others self image. Each patient's own list of beliefs is read and in a
discussion, guided by the therapists, the group compares the three lists,
and explores the patient's self-image, its similarity to the group opinion,
the accuracy of the group's "guess" of the patient's self-image (usually
very high), and the implications of each to the patient's life. This is done
with each patient in turn.
There is usually at least one patient who has not done the assign-
ment. The patient almost invariably presents an excuse that avoids re-
sponsibility for the assignment (e.g., "There was no time to do it"). The
excuse is discussed and provides an opportunity to demonstrate the
difference between responsibility avoiding and responsibility accepting
for any action or inaction.
The therapists make a brief presentation of the model that thoughts
determine feelings which together determine behavior and a number of
examples are given which pertain to the group members. Following this,
the therapists discuss the potential benefits of controlling and determin-
ing one's feelings and behaviors and explain how this is possible by
controlling one's thoughts.
Two cognitively oriented self-help guides, the Ellis and Harper
book (1975) and the Beck and Greenberg article (1974) are made available
to those who are interested and a "monitoring" assignment is given.
The patients are asked to describe in writing for the seventh session two
strong feelings they have had, the thoughts that preceded the feelings,
and the behavior that followed.
Sessions 7 and 8
Goals 1. To review the patients' progress in reaching the goals they
selected in the Goal Attainment Scale, to discuss the relation-
ship of different thinking patterns to the accomplishing of
goals, and to identify specific conceptualization problems that
the patients have in relation to their goals
2. To help patients to understand and accept the Thought~ Feel-
ing~ Behavior model
3. To help patients to become aware of their own Thought~ Feel-
ing~ Behavior patterns, to identify and help them to become
aware of irrational or maladaptive thoughts, and to demon-
strate the relationship of these to their feelings and behaviors
4. To develop further the distinction of facts from opinions and of
maladaptive or irrational thoughts from adaptive or rational
thoughts and to demonstrate the consequences of each
5. To help patients to develop a continuous awareness (or
monitoring) of their thoughts
Patients are given a copy of their Goal Attainment Scale and are
asked to report on the progress they have made. They discuss the diffi-
culties they are having in reaching their goals and the discussion focuses
on these difficulties in terms of the cognitive model of feelings and
behavior.
The patients' monitoring homework assignments then are ana-
lyzed. This is accomplished by writing the patient's assignment on a
blackboard and having the group discuss it. The therapists conduct the
discussion in which emphasis is placed on the organic connection be-
tween thoughts and feelings and the behaviors that follow. The focus of
attention is turned to the thoughts themselves. These are discussed in
terms of their internal logic, their hidden assumptions, their relationship
to reality, their adaptiveness or maladaptiveness to the patient's life,
alternative thoughts the patient might have, and the potential benefits
of these alternative thoughts. Approximately one-third of the time the
thoughts are ones that lead to a feeling of wanting to drink. During the
sessions, the therapists often apply the above analysis to the feelings
that arise during the group meetings. If a patient displays any noticeable
emotion, he immediately is asked to share with the group the thoughts
that preceded this emotion. Imaginal role playing often is used to ex~
plore Thought~ Feeling~ Behavior (TFB) patterns and role playing and
reenacting by the patients are also used.
The monitoring assignment is given for the ninth session.
In order to help the therapists and the patients learn more about the
conceptualizations of the group members, the patients are asked to meet
individually with one of the therapists and to take a modified version of
the Kelly Rep Test (Kelly, 1955). The modification is called the Situations
Rep Test (Glantz, 1982) and focuses on thoughts about interpersonal
and noninterpersonal experiences and situations. The results are dis-
cussed with the patient.
Sessions 9-12
Goals 1. To continue the analysis of thoughts, feelings, and behaviors
2. To develop the idea of alternative thoughts with the goal of
determining one's own feelings and behaviors
3. To instill in the patients the habit of utilizing alternative modes
of thinking as a countermeasure to negative thoughts and feel-
ings and to learn to do so using negative thoughts or feelings as
a cue to begin the process of using alternative self-statements
Monitoring assignments and in-group experiences are analyzed by

the group using the TFB model. As the patients develop an understand-
ing of the model and its application, they are encouraged to explore the
idea of determining and controlling their feelings and behavior. The
group discusses the feelings and behaviors that would result from vari-
ous modes of thinking and considers the benefits of the more "adap-
tive" thoughts and the possibility of substituting the more adaptive
thoughts for the maladaptive ones. This leads to the idea of using adap-
tive thoughts, in the form of self-statements, as a countermeasure to the
maladaptive thoughts and their feelings and behavior. As the patients
accept these ideas and become aware of their own maladaptive
thoughts, they are encouraged to practice and develop the habits of
utilizing the more adaptive modes of thinking.
Attention is devoted to the utilization of the onset of negative feel-
ings or behavior or maladaptive thoughts as cues to the individual to
begin the alternative and more adaptive thoughts in the form of self-
statements. Once a patient has had the experience of an alternative and
more adaptive thought leading to a more positive feeling and/or behav-
ior, then he usually has passed a critical point and will adopt and benefit
from the therapy and its philosophy relatively easily. For this reason,
patients are often encouraged to "try an experiment" in which they
attempt to think about something "differently" or at least try to behave
as if they had a different conceptualization of a person or a situation.
In order to concretize comments about the patients' thoughts and
self-image, the therapists and the group often rate them on a 1 to 10
scale, indicating a range between high and low self-image, extreme opti-
mism and extreme pessimism, overacceptance of responsibility and un-
deracceptance, maladaptive and adaptive thinking, and so forth. This
rating technique also is used to concretize the difference between an
individual's opinion and the groups opinion and to concretize change
and progress.
A monitoring assignment is given for the eleventh session.
Sessions 13 and 14
Goals 1. To review the patients' progress in reaching the goals they
selected in the Goal Attainment Scale, to discuss the relation-
ship of different thinking patterns to the accomplishment of
goals, to identify specific conceptualization problems that the
patients have in relation to their goals, and to develop alternate
and more adaptive thought patterns that will facilitate selecting
and reaching a desirable and realistic goal
2. To demonstrate how physical-somatic factors relate to concep-
tualizations and to demonstrate some techniques for control-
ling some somatic responses
3. To demonstrate a model for understanding and controlling im-
pulsive and explosive behaviors such as angry rages
The patients' Goal Attainments Scales are discussed as before. A
strong emphasis is placed on thought patterns and alternate conceptual-
izations and their relation to selecting and reaching goals.
In a discussion format, ·the therapists demonstrate how internal
behaviors or physical reactions also fit into the TFB model. It is ex-
plained that thoughts determine these behaviors and, as is often the
case with TFB patterns, there is a feedback effect. Once the behaviors are
initiated, awareness of and thoughts about the behaviors reinforce and
amplify the original thoughts, which lead to a greater reaction and so
on.
Alcoholics almost seem "to think with their bodies" in that they are
especially sensitive to somatic feedback and frequently follow this cycli-
cal pattern. Many alcoholics report having a feeling of overwhelming
anxiety and physical tension or deep depression and physical lassitude.
The TFB model is used to explain these experiences and emphasis is

placed on the idea that these feelings are produced by and are controlla-
ble by thoughts. The idea of a feedback system is explained and a ver-
sion of Schacter and Singer's (1962) model of affective reaction is pre-
sented. As the therapists and group members explore particular
patients' TFB patterns, the therapists demonstrate specific behavioral
techniques to help combat the habituated response patterns. Tense pa-
tients are encouraged to take a few deep breaths or use muscle relaxa-
tion techniques that are taught in training classes at the clinic. Inactive
patients are encouraged to become physically active.
A number of our patients report that they are subject to impulsive
and explosive behaviors such as angry, often violent, rages. These be-
haviors also are discussed with the above ideas and an approach in
controlling impulsive behaviors is taught. Novaco (1977) has developed
Meichenbaum's stress inoculation procedure (1975) for use in anger con-
trol and the therapists teach a version of this procedure. The approach
involves three basic phases. The first is a cognitive preparation stage
that essentially is the application of the above cognitive model to the
experience of anger. The second phase involves skills acquisition and
rehearsal which includes the learning of alternative conceptualizations
and self-statements, the development of a task orientation or problem-
solving approach to anger situations, and the utilization of the above
somatic techniques. The third phase involves application practice.
The assignments for the fifteenth session are practicing and apply-
ing the tension, lassitude and anger control techniques and identifying
two important problems to work on.
Session 15-18
Goals 1. To teach patients problem-solving skills and strategies, to dem-
onstrate the relationships between thoughts and feelings, and
problems and problem solving, and to help the patient to work
out particular problems
Most of our patients do not really know how to go about solving
real world problems in a rational organized way. They typically act in an
ineffective, impulsive manner and feel that their problems are insoluble.
Building on the model of TFB, a modified version of D'Zurilla and Gold-
fried's (1971) problem-solving strategy is taught. Patients are presented
with the idea that there are five basic steps that they should take when
solving a problem:
1. a) Determine that there is a problem and that it is a problem that
you want to solve.
b) Define the problem in specific, concrete, operational terms.
2. a) Determine the possible goals or resolutions.

b) Evaluate each and select one.
3. a) Determine the possible paths to the goal or resolution.
b) Evaluate each and select one (or more).
4. a) Take the first step on the path to the goal or resolution.
b) Continue to work toward goal or resolution.
5. As you are working toward the goal or resolution, check to make
sure that the path you are on is leading to the goal or resolution.
During these sessions each patient presents at least one important
problem and, with the help of the therapists and the other group mem-
bers, works toward solving it using D'Zurilla and Goldfried's strategy.
This is an extremely difficult exercise for the patients and requires a
great deal of help from the therapists and often involves consideration of
TFB patterns. The most difficult step for the patients seems to be the
definition of the problem in specific concrete, operational, objective
terms. They typically think of problems in global amorphous ways that
have no implied resolutions or courses of action and, in fact, often imply
irresolvability (e.g., "I want things to be the way they were 20 years
ago"). Not infrequently a problem is identified and thought of by the
patient in terms of a vague wish-fulfilling fantasy (e.g., "I want to meet
the woman of my dreams"), a poorly articulated conflict (e.g., "Why
can't I work like everyone else"), or one problem that serves as an
expression of a number of poorly thought out interrelated problems,
(e.g., "I haven't been able to finish building a chair for my girlfriend,"
which encompassed problems related to the patient's relationship to his
girlfriend's family and his lack of an apartment of his own which
stemmed from his lack of a job). By working on specific problems, pa-
tients learn the problem-solving strategy. The patients' Goal Attainment
Scales also are utilized in these problem-solving exercises.
Assignments are given during these sessions that involve having
the patients work on a step of the problem solving.
Sessions 19 and 20
Goals 1. To review and integrate the material and the exercises of the
group, to answer any questions or discuss any issues that the
patients might have, and to help patients to plan to continue
the tasks and ideas they began in the group
2. To have the patients complete (for a second time) the assess-
ment exercises for a pre-post comparison
After the patients have completed the exercises, they discuss what
they have learned from the group, issues that they are concerned about,
and their plans for the future.
Discussion
The goal of the cognitive therapy groups is the teaching of gener-
alized coping and reconceptualizing skills that go beyond the specific
content of the problems that are dealt with in the group. It is for this
reason that maladaptive thought processes are such an important target
of the therapy. If these are ameliorated, then not only may the concomi-
tant maladaptive themes be remedied, but the patient is more likely to
develop an enduring generalized adaptive conceptualizing system that
will enable him to avoid the development of other maladaptive themes
and enable him to cope successfully with both his current environment
and new situations. An important goal of the therapy is to teach the
patient the philosophy of the cognitive approach to behavior and the
means by which he can identify and change maladaptive thoughts so
that he can, in effect, become his own therapist and continue the benefi-
cial changes on his own after the termination of the group.
Although the topics of the group discussions and exercises are often
oriented around affects and behaviors, the ultimate target of the therapy
and the modality through which it operates are cognitive in nature.
Although the therapy involves some behavioral skills training, for the
most part it is assumed that the patients have, at least to some degree,
the necessary adaptive practical and interpersonal skills and it is further
assumed that the problem is to help them to identify and use those skills
when appropriate. This approach usually means that the patient is
helped to learn to substitute one behavior for another rather than en-
couraged simply to stop a particular behavior, such as drinking. For a
number of patients, however, we have found that instruction in relaxa-
tion training and assertiveness training can provide an important sup-
plement to the patients' repertoire of adaptive alternative behaviors and,
perhaps more importantly, increases their confidence in their ability to
initiate an alternative adaptive response.
Initially, we anticipated that the patients who would benefit most
from the cognitive therapy group would be those who were verbal,
reflective, intelligent, educated, and have a belief in the potency of
thought. Our expectations have not been verified. Although the therapy
did not work equally well with all patients, we are unable at this time to
preselect those patients who will benefit most. We are, however, able to
describe some of the characteristics of the responsive patients that are
observable during the therapy. The patients who appeared to benefit
from the cognitive therapy seemed to have three characteristics in com-
mon: (1) They were motivated toward change. (2) They accepted the
cognitive-behavior philosophy and its implications. (3) They had some
experience in which they benefited from a reconceptualization and the

application of the cognitive techniques. As much as possible, each pa-
tient should be an active collaborator in the attempt to bring about
therapeutic change rather than a passive recipient of a treatment.
Although some patients readily accepted the cognitive-behavior
philosophy, others resisted it. Despite repeated efforts to make the phi-
losophy concrete, it remains too abstract and esoteric for some patients.
Other patients resist because accepting the model would mean accept-
ing responsibility for their thoughts, feelings, actions, and problems.
Some patient's feelings are so dominantly pervasive and overwhelming
that they believe that their thoughts have little if any impact and that the
therapy was, therefore, useless to them.
We believe that patients learn best through a process of doing and
experiencing. Although the didactic presentation of concepts and dis-
cussion obviously is necessary, ideas must be assimilated both experien-
tially and behaviorally. For many of our patients, talk alone appears to
have minimal impact. Therefore, it is essential that discussion be supple-
mented by in vivo experiences, role playing, homework assignments,
reality testing and behavior change "experiments" and the development
of self and other monitoring skills. We would agree with Beck (1976),
Meichenbaum (1977), and others who have advocated the use of a multi-
modal therapy strategy. We have found the 20-session group cognitive
therapy to be a potent intervention strategy. For most patients, howev-
er, it is necessary for them to participate in some form of treatment after
the 10-week course of therapy.
For most of our patients, the severity of their psychopathology, the
magnitude of the disruption and/or impoverishment of their social net-
works and interpersonal relationships, the deterioration of their em-
ployment and financial situations, and the relative inaccessibility of so-
cial support, and tangible resources combine to make positive change
and recovery a long and difficult process. Although the cognitive thera-
py can ameliorate much of their psychopathology and can increase their
coping skills, it cannot bring about direct remediation of those other
problematic factors. Therefore, we recommend that after the cognitive
therapy groups, patients continue in some form of counseling support
(such as Alcoholics Anonymous) or individual cognitive therapy. Our
patients typically are referred for individual therapy which is sometimes
supplemented by attendance at AA meetings or other support or thera-
PY groups at the clinic. While we believe that the cognitive therapy
approach, using a structured format and a relatively small predeter-
mined number of therapy sessions, is very effective, we have been con-
sidering expanding the protocol to 25 or 30 sessions or creating a follow-
up or maintenance group to provide additional therapeutic support.

Also, while the protocol is fairly structured, we do not believe that the
cognitive therapy can be an invariant procedure that is the same for all
patients. We try to be flexible and to create an individual therapy plan
for each patient and to adapt the therapy plan for each new group to the
particular members of the group. We are considering ways to increase
the flexibility and the responsivity of the protocol. Despite our desire to
improve the cognitive therapy protocol we have had considerable suc-
cess with this program of therapy and feel that it can be used successful-
ly by others.
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9
Cognitive Therapy with the
Young Adult Chronic Patient
VINCENT B. GREENWOOD
Recently, there has been an effort to extend the application of cognitive

therapy to different patient populations (Emery, Hollon, & Bedrosian,
1981). In that spirit, I should like to share my experiences and observa-
tions in applying group cognitive therapy to a very difficult patient
population, the young adult chronic patient. To my knowledge, this is
the first attempt to apply cognitive group therapy to this patient popula-
tion.
PATIENT PoPULATION
Since the advent of deinstitutionalization, a difficult patient group

has emerged, known as the young adult chronic or "revolving door"
patient. These are patients-mostly in their 20s and 30s-with serious
psychiatric disabilities. They are the first generation of mental patients
forced to cope with the stresses and demands of community living (Pep-
per, Kirshner, & Ryglewicz, 1981). They do not cope well, and conse-
quently become perpetual or recurrent clients of mental health systems,
social service agencies, and-frequently-the legal-penal system. They
pose treatment and service delivery system dilemmas that are signifi-
cantly different from those posed by earlier generations of the severely
mentally disabled.
The great majority of these patients carry an Axis I diagnosis of
schizophrenia. In addition, many display severe borderline pathology.
VINCENT B. GREENWOOD • Center for Cognitive-Behavioral Therapy, 5225 Connecticut

Avenue, N. W., Washington, D.C. 20015
183
184 VINCENT B. GREENWOOD
Although their symptom pictures vary greatly, there is considerable

similarity in their functional characteristics. All these patients display
severe difficulties in so'cial functioning. They have few social or voca-
tional skills and no natural support systems. Thus, what is an everyday
problem in living for us becomes a crisis for them. When under such
stress, they show serious disorders in reality testing, affect modulation,
and impulse control, exhibiting both aggressive and self-destructive be-
havior (Schwartz & Goldfinger, 1981).
Perhaps the most problematic characteristic of these patients is their
lack of involvement in treatment. They do not define themselves as
mental patients. They typically are brought to the hospital against their
will and often feel victimized by the mental health system. Their hospi-
talizations are often stormy and they end up rejecting treatment-vehe-
mently or passively. The burden, consequently, rests with the mental
health system to design treatments that will be responsive to this new
class of psychiatric "untouchables."
In attempting to tailor cognitive therapy to this patient group, I
have observed different stages over the course of psychotherapy. (I am
defining stage as a set of therapist operations designed to effect reliable
changes in the patient.) Detailing treatment in stages seems particularly
useful with this patient population who are notorious for their lack of
involvement with and adherence to psychotherapeutic approaches.
Anthony, a leader in the development and evaluation of rehabilita-
tion treatment packages for the severely psychiatrically disabled, has
recently (Anthony, 1980) proposed an innovative outcome evaluation
model that incorporates specific stages of involvement and understand-
ing. In this model, it is crucial that evaluators assess the extent to which
patients become involved with and understand treatment before at-
tempting to evaluate outcome. Likewise, clinicians working with this
patient group need to address specifically these issues of involvement
and understanding. It would be unfortunate to reject a particular treat-
ment modality merely because the patient has not been sufficiently "ex-
posed" to the essential ingredients of the treatment. It would be equally
unfortunate if practitioners did not make modifications in a particular
treatment approach in order to ensure that patients are exposed to the
more potent aspects of the treatment.
Thus, the straightforward application of cognitive therapy, as, for
example, outlined in the Cognitive Therapy of Depression (Beck, Rush,
Shaw, & Emery, 1979) rests on a number of assumptions that are invalid
with the young chronic patient. Engaging the patient in a collaborative
analysis and treatment of his or her problematic behavior and cognitive
distortions rests on the following premises:
THERAPY WITH THE YOUNG ADULT CHRONIC PATIENT 185
1. The patient is motivated to seek treatment.

2. The patient acknowledges he or she has a psychological problem
(i.e., patient has a minimal degree of insight).
3. The patient has the belief that it is acceptable to self-disclose.
4. The patient is capable of attending to and understanding the
treatment that is being offered.
5. The patient is capable of acquiring some of the fundamental
skills that are the focus of cognitive therapy (e.g., introspection,
disputational skills, an empirical problem-solving style), (Becket
al., 1979).
The above-noted qualities typically are present at the outset of treat-
ment with those suffering affective or anxiety-based disorders. With
psychotic patients, they are not present. Consequently, the cognitive
therapist who is unwilling to actively seek appropriate modifications
will be frustrated in his or her attempts to administer the armamen-
tarium of behavioral and cognitive change strategies.
STAGES OF TREATMENT
Three stages of group cognitive therapy with the young chronic

patient have been abstracted. The first stage has an explicit agenda of
securing the patient's involvement in treatment. The second stage tries
to facilitate the patient's understanding of the cognitive therapy treat-
ment process-what Becket al. (1979) and others have termed the "so-
cialization" stage. The third stage involves the application of specific
cognitive and behavioral change strategies with the primary goal of
helping patients change their maladaptive perceptions and ideas.
These stages, as just described, are generic stages, which probably
would be utilized in the treatment of almost any clinical disorder. When
compared with the course of therapy for neurotic disorders, however,
significant differences arise with regard to the timing, effort, and tech-
niques involved in consummating each stage.
THERAPY GUIDELINES
The major guideline for therapists in conducting this kind of group

is to develop a sophisticated appreciation of the cognitive viewpoint
(Beck, 1976) so that group phenomena and change strategies can be
conceptualized in cognitive terms. It would be useful at this point to
reiterate and highlight the distinctions made by Glass and Arnkoff

(1981) and others between therapy process and therapy procedure.
Therapy process refers to the model of change that underlies a course of
therapy, while therapy procedures refer to specific techniques used to
bring about change. The cognitive therapist will find this distinction
particularly useful with this patient group. Given the "multimodal"
nature of pathology in these patients, it is important for the therapist to
delineate an internally consistent view of the therapy process. This will
allow the therapist to experiment with a wide range of techniques in an
orderiy and coherent fashion. Perhaps more so than with other disor-
ders, therapists must "think cognitive" and yet operate in a multimodal
fashion in order to exploit opportunities for constructive change.
Another guideline in the group treatment of these patients is the
desirability of multiple therapists. There are a number of reasons for this
recommendation. The psychological make-up of these patients is best
apprehended by both a group-process and a problem-oriented focus.
Patients become more keenly aware of their distorted perceptions and
unrealistic premises when they arise in the group process. When such
distortions are triggered, a vigorous, directive, and often didactic ap-
proach is required to help patients disengage from, and then critically
evaluate, their cognitive distortions. The use of co-therapists provides a
division of therapeutic attention and labor that helps ensure that distor-
tions are first attended to, and then challenged. In addition, given the
attentional difficulties and volatile interpersonal styles of many of these
patients, management of the group (e.g., gate-keeping functions, limit-
setting, etc.) could overwhelm a single therapist. Finally, some of the
most useful techniques, such as modeling and role playing, require the
presence of at least two therapists.
The outline of treatment strategies for the cognitive group therapy
of psychotics are elaborated to include: (A) the goal of the stage, (B) the
guiding principles or basic schemata in the therapist's mind that guide
his or her behavior, (C) process criteria-specifically, the cognitive
change or shift desired in patients-that enable the therapist to judge
when the stage is completed, and (D) specific techniques found useful.
The group itself consisted of 8 patients recruited from a ward for
young adult chronic patients at a large public psychiatric hospital. Two
therapists conducted the group. With a maximum of 8 patients at any
one time, the group met once weekly for 10 months. Turnover in the
group was minimal with a total of 12 patients involved during the life of
the group. The therapists were supervised on a weekly basis by the
director of training at the Center for Cognitive Therapy in Philadelphia.
Stage I: Involvement
The first stage of therapy aims to secure the patient's involvement
in treatment. In order to underline the need for this state, I would like to
portray the quality of the resistance that these patients revealed when
anticipating involvement in group treatment. Comments from the first
few sessions reveal concerns more intense and of a different degree than
the usual neurotic fears regarding involvement in groups.
• "When I talk, I feel obsolete."
• "I can't sit in the same group with these people, since they are
sinful."
• "If I reveal my problems, others will catch them."
Almost all patients indicated that they would suffer serious harm, or
inflict serious harm, by becoming involved in group treatment. Such
concerns include but go beyond the approval and performance anxiety
preoccupations of neurotics. Concerns over fusion, disintegration of
one's identity, persecution, and loss of control were aroused by the
invitation to group treatment.
Given the intensity and interpersonal nature of these anxieties, the
guiding principle at the outset of treatment was to create a trusting
emotional climate in the group by achieving strong patient-therapist
rapport. While acknowledging that the establishment of a warm and
genuine patient-therapist relationship is a time-tested treatment princi-
ple applicable to almost all disorders, it is particularly salient for this
patient group.
Initially, the group itself must acquire motivating properties for the
patient. These patients, unlike neurotics, do not identify problems in
their social lives that they feel motivated to solve. Both the primitive
nature of their prominent defense mechanisms and the apathy and de-
spair that dominate the conscious life of these patients emphasize the
need to make the group experience itself gratifying. These patients seem
unable to perceive a better way to live their lives. Until such hope is
instilled, the group needs to be a haven of interpersonal nourishment.
Although I agree with Ellis (1959) that the realization of a warm and
genuine patient-therapist relationship characterized by unconditional
positive regard is not a necessary condition in working effectively with
neurotics, it appears to be a necessary, although by no means sufficient,
condition for change with this severely disabled group. When patients
link their heightened involvement in the therapy process with their
liking for the therapist, it is fair to assume that the realization of the core
facilitative interpersonal conditions can ameliorate significantly the

often noted motivational and attentional problems of these patients.
The cognitive shift desired in patients during this stage would be
from rejection to acceptance, from "I can't tolerate this group ... it is
irrelevant ... I don't need it" to "This is a relatively safe place where I
can get help for some of my problems."
To establish rapport and secure the patient's involvement in treat-
ment, the therapist needs to seek behaviors consonant with the core
facilitative conditions of respect, genuineness, and empathy as original-
ly highlighted by Rogers (1957). These strategies are advocated after
having observed that they lead to change in the patient's cognitions of
involvement in treatment and not because they represent necessary and
sufficient conditions of change.
The following are some of the guidelines and specific therapist be-
haviors found particularly beneficial with psychotic patients.
Two guidelines are advocated in the expression of empathy at the
beginning of treatment: (1) err on the side of ensuring that the patient
feels understood, rather than articulating beliefs or implicit attitudes
that are out of his awareness; and (2) when the therapist's comments
"go beyond" what the patient is immediately expressing and experienc-
ing, they always should be in the service of reducing, rather than in-
creasing, the patient's anxiety.
I have found therapist self-disclosure to be a potent intervention in
cutting through patient denial. Particularly when therapists reveal they
have problems similar to patients' (e.g., communicating with others,
feeling put down, loneliness), a very open discussion of these issues
often ensues. After such a discussion it is much easier to illuminate the
cognitions that contributed to the denial (e.g., "If I admit my difficulties,
people will think I'm homosexual").
Therapist self-disclosure in the initial stage of treatment should con-
vey the cognitive view, provide structure, and invite-rather than de-
mand-participation. An illustration:
When I'm in groups, I often get scared. I worry that I will appear foolish. If I
tell people some of the things I am thinking, they may not like or respect me.
I'd like to know if others have this fear also. But first, let me say I try to fight
off this fear by reminding myself people are usually more understanding and
sympathetic. Also, when I force myself to speak up, I often find others have
similar problems and can be quite helpful to me.
Communicating understanding and tolerance for the patient's self-

defeating behavior also seems to be essential for future collaboration. An
immediate or zealous focus on change automatically can elicit severe
resistance to, if not actual flight from, the group.
THERAPY WITH THE YOUNG ADULT CHRONIC pATIENT 189
Other interviewing guidelines that would be suggested at the be-

ginning of treatment include reinforcing reality testing; supporting am-
biguous defenses of the patient; keeping comments brief and directive
(avoid open-ended interpretations); and accentuating friendly nonver-
bal behavior, such as shaking hands.
Because psychotic patients often can bring such intense resistance
to therapy, it is somewhat surprising that such patients exhibit a good
deal of cognitive and behavioral change regarding their involvement in
group treatment after a relatively brief period of time. After eight ses-
sions attendance was stable. As for the patient's involvement in treat-
ment, the following comments provide anecdotal evidence of a cognitive
shift.
• "People in here don't look so mean anymore."
• "This group is like a family."
• "I wish we could meet more often."
• "You can really talk about anything in here."
What counts for such dramatic behavior change? The following
quote by Beels (1980), a leading spokesman in the treatment of this
patient group, captures the poignant experience of such patients at the
outset of treatment and provides some understanding as to why pa-
tients can change their group behavior significantly in a brief period of
time.
In the psychotic state, and to some degree after it has subsided, a person's
experience of initiative, distance and exchange has changed. Schizophrenics
often feel great anxiety at the simplest initiatives. Their difficulty in carrying
out greetings and negotiations with strangers is famous and the reason why
evidences of thought disorder are especially present in the psychiatric inter-
view. There is difficulty over control with social distance. Feelings of pursuit
and rejection may overwhelm the patient in situations where for most of us
there is merely the problem of encouraging someone or putting someone off.
What is manners for us, is for him an operatic nightmare. (p. 10)
Once psychotic patients perceive the therapist as someone they can

rely on to respond sensitively to and guide their awkward and anxiety-
laden attempts to communicate with others, they seem willing to risk
much greater involvement in the therapy process.
Stage II: Understanding

The next objective is to facilitate the patient's understanding of the
cognitive therapy process and to create a working alliance focused on
how problems can be solved. Again, it would be unwarranted to assume

that these patients possess insight into the cognitive therapy process.
Doses of time and creativity are required to impart this understanding.
Recently (Gardner, 1980; Heitler, 1976; Lorion, 1974), there has been
empirical support for the unfortunate clinical observation that low~in
come, poor prognosis patients tend to have very little idea what psycho-
therapy is, how it can help them, and how they can involve themselves
in the therapy process. The skills required to become meaningfully en-
gaged in the therapy process very often are lacking. In Stage I, it was not
that patients did not possess the skills to become involved in group
treatment, rather that they had "negative" cognitions regarding such
involvement. In this next stage, it is not that patients had negative
cognitions about the therapy process, rather that they had very few
cognitions at all.
In the second stage of treatment, the therapist must become much
more directive and didactic. However, as he or she is trying to bring to
life the cognitive viewpoint-specifically, that people create their own
feelings and determine their own behavior by the way they think and
perceive-he or she quickly collides with one of the cardinal features of
this patient group; namely, their ingrained projective defenses. At this
stage, patients acknowledge that they have serious problems in living
and suffer from some searing emotional states. The cause of their suffer-
ing, however, does not reside in their maladaptive thinking but some-
where "out there," in the real or imagined environment. The notion that
people can control their own destiny is a radical notion for neurotics and
normals. For psychotics, it is revolutionary.
The guiding principles in the therapy during Stage II are, first, to
convey the central role of thinking on the person's affect and behavior;
and, second, to encourage self-attributions of internal causation. In each
session, after important interchanges or role-playing exercises, care
would be taken to highlight the cognitive underpinnings (e.g., "If you
think _ _, then you'll feel/behave - - · Whereas, if you think
_ _ , then you'll feel/behave _ _"). The cognitive shift desired in
patients during this stage is from mystification (e.g., "I don't under-
stand what therapy is") and helplessness (e.g. "He, she, it or they are
causing my suffering") to understanding and control (e.g., "I can re-
duce my suffering and achieve my goals by changing the way I think
about and interpret life experiences").
Before listing some of the specific techniques we found to be most
useful in the socialization process, I would like to abstract a broad strate-
gic principle that applies throughout the course of treatment, but which
is particularly noteworthy in this stage: Employ techniques that take into
account the attentional difficulties of these patients. Of the broad range of

cognitive deficits in this patient group, the most problematic is their
inability to attend, and to filter out irrelevant stimuli in their environ-
ment. It is therefore important to use strategies that capture the patient's
attention and involve him or her actively. This is particularly true in the
group situation where it is difficult to monitor and solicit constantly each
patient's attention throughout the session.
To convey the cognitive view, one of the most helpful techniques
was modeling. One teaching technique was for the therapists to plan
"skits" to demonstrate the essential role of cognitions in determining
one's reactions to an event. We would, for example, act out the same
scene-waiting for a friend who was late-a number of times, modeling
self-talk indicative of anger, self-disparagement, or indifference. After
the skit, we would highlight the cognitive viewpoint by comparing vari-
ous concrete reactions.
The ABC model (Ellis, 1962), because of its simplicity, proved to be
an effective vehicle to teach the cognitive view. One strategy that mobi-
lized group members' attention would involve the therapist clearly la-
beling the A (activating event) and C (emotional consequence) compo-
nents of an emotional episode, and then asking all group members to
figure out possible self-statements (B) that would have led to the emo-
tional consequence (C).
An important objective during this stage of treatment was to help
patients disengage from the self-defeating automatic perceptions and
reactions that occurred in the group. Therapists would offer a model on
how to disengage by constantly "collecting data" regarding how pa-
tients were reacting to one another and to the therapists and by probing
for the implicit assumptions that are fueling such reactions (e.g., "Mary,
you look crushed when I cut you off. What are you thinking and feeling
right now?").
"Checking it out" soon became part of the group culture as indi-
cated in the following comments by patients:
• "I'd like to know when others are reading my mind."
• "Why are people always looking at me in here?"
• "You must think I'm a sissy now that you know I was molested as
a child."
After approximately 12 sessions, a majority of patients in the group
were demonstrating a rudimentary understanding of the cognitive
model by initiating attempts to analyze problems in terms of self-state-
ments. I also was heartened by reports from other staff members that
this behavior was generalizing beyond the cognitive therapy group.
Stage III: Cognitive Restructuring

It was at this point that I believed it was time to introduce cognitive
and behavior change strategies-specifically designed to alter the mal-
adaptive thinking of group members-with some confidence that such
strategies would not be met with confusion or resistance.
The cognitive shift desired in patients during this stage is difficult to
capsulize or parsimoniously summarize as I have tried to do in Stages I
and II. The range of information processing distortions and of dysfunc-
tional underlying assumptions is much greater than in other disorders. I
will, however, list some of the most common information processing
distortions that occurred in the group with examples of some of the basic
assumptions or core beliefs that accompanied these distortions.
1. Selective Abstraction and Arbitrary Inference. These distortions usu-
ally occur simultaneously and refer to the process whereby the patient
first focuses on a particular detail in the environment and then draws a
conclusion that is unwarranted if he or she were to consider other rele-
vant data. In depression, this type of dysfunctional thinking usually
takes the form of a disparaging personalization. In the group there was a
more ominous theme. Patients were vigilantly scanning the environ-
ment for "clues" to support hypotheses concerning danger and threat.
A major primary assumption that fuels this style of thinking is that
everything has meaning; or, specifically, that people constantly are
sending messages of hatred to me.
2. Dichotomous, That Is, Ali-or-None Thinking. This refers to the ten-
dency to think in absolute terms. This characteristic, which many con-
temporary theorists label "splitting," is a thinking pattern that is well
ingrained with this group. It is seen vividly when patients describe
themselves or significant others in their life. They frequently describe
themselves and others as all good and powerful, or as all evil and utterly
ineffectual. Some of the primary assumptions that underlie this thinking
pattern include: If part of me is bad, all of me is bad; and, If you do not
love me, you hate me.
3. Magnification, That Is, Catastrophizing. This refers to the tenden-
cies to exaggerate or overestimate the meaning of a particular event, or
its future negative consequences. This cognitive predisposition repre-
sents one of the most devastating components of schizophrenic illness.
This pattern frequently is elicited when such patients make tentative
steps to face themselves and their limitations more realistically, or when
they begin to take some initiative in overcoming their withdrawal ten-
dencies. Such steps take on what appears to be a life and death struggle.
The predominant underlying assumption accompanying the cata-
strophizing response is: Psychological and behavioral risk taking results

in annihilation.
4. Faulty Attribution. This is the process whereby the patient se-
verely underestimates or overestimates the extent to which he can con-
trol his or her behavior, the behavior of others, and events in the world.
The basic assumptions here seem to be: I have no control over my
thoughts, feelings, or behavior. Voices, demons, and so forth have con-
trol. If I wish something, it will happen.
Because the pathology in the new chronic patient is so severe and in
some respects intractable, it is essential for the cognitive therapist to
develop a realistic framework to gauge change. It quickly was dis-
covered that certain constraints and qualifications had to be added to
those cognitive change principles proven effective with other patient
groups. These qualifications can be translated into the following strate-
gic principle: The focus of cognitive restructuring strategies should not be on
the central characteristics of the patient's thought disorder.
This principle dictates trying to avoid interactions that require the
patient to overcome some of the cardinal features of his or her disability.
Thus, strategies that are contingent upon the patient's ability to intro-
spect, to make subtle semantic distinctions, to employ an empirical
problem-solving style, to generate and sustain a continuous cognitive
horizon of alternative hypotheses, or to dispassionately challenge delu-
sional thinking are unlikely to succeed. It is unclear at the present time
whether such deficits are absolutely refractory to change or whether
they might be ameliorated in a later stage of treatment. It is evident that
socialization to the cognitive therapy model itself is not sufficient to
produce change in these areas.
One implication of this viewpoint is to focus on the patient's distor-
tion of events and interactions rather than upon his underlying beliefs
and premises. Given the very real impoverished existence of most of
these patients, the more "elegant" cognitive therapy goal of getting the
patient to challenge irrational premises regarding personal worth or
achievement is unrealistic. Distinctions between "awful" as opposed to
"quite frustrating" circumstances have little meaning for this group.
What does appear to have a great deal of meaning is to demonstrate
that, although mired in a truly sorry state of affairs, they do distort
events in a way that reinforces their avoidance tendencies and sense of
worthlessness.
Once patients in the group reduced their reliance on the defenses of
denial and projection, they revealed that they rather consistently over-
reacted to interpersonal stimuli in a negative fashion. Things really are
not as miserable or threatening as they construe them. Thus, a good deal
of time is spent helping patients discriminate between what Walen,

DiGiuseppe, and Wessler (1980) have termed "confirmable" reality and
"perceived" (i.e., distorted) reality. The following examples illustrate
this point.
KATHY: When you said patients on the ward bothered you, I guess you meant
me.
ROBERT: No, not you Kathy, I was talking about ...
KATHY: That's a relief.
THERAPIST: Kathy, I notice when someone mentions something negative, you
often assume you're to blame.
CHARLES: I stopped the conversation because I knew Deloris was bored with me
and didn't want to talk.
THERAPIST: Is that true?
DELORIS: Not really. I was preoccupied with something else ... I sort of wish
we had talked longer.
THERAPIST: Charles, when a conversation doesn't go well you assume it's be-
cause there's something wrong with you and you end it.
The above examples reflect how these patients have deep-rooted

premises that greatly contribute to their avoidance of others. The de-
sired outcome of such interventions is slowing down the patient's auto-
matic responses to interpersonal stimuli and introducing into their con-
sciousness alternative, more realistic ways of interpreting events.
Another effective intervention during this stage was stress in-
noculation training (Meichenbaum, 1977), using modeling and role play-
ing as a teaching medium. First, therapists would articulate some of the
distortions and irrational assumptions triggered when faced with a
stressful encounter (e.g., approaching someone to initiate a conversa-
tion). Therapists would then model coping self-statements before, dur-
ing, and after the encounter. Patients were then asked to role play the
same social situations using the coping self-statements.
The strategic principle applies to delusional thinking. Our attempts
to encourage patients to re-evaluate aspects of their delusional system
typically result in increased guardedness. Jacobs (1980) recently has in-
troduced the distinction between thinking and knowing. Thinking is
characterized as an endless dialogue we constantly carry on with our-
selves in solitude. Thinking is governed by reason. Knowing, on the
other hand, is more of an awareness of truths, such as knowing one is a
man or woman. Jacobs contends that knowing cannot be directly altered
by thinking or metathinking (i.e., thinking about thinking). It is likewise
our clinical experience that delusional thinking, particularly grandiose
delusions of the self, are never fully surrendered. The patient's delu-
THERAPY WITH TilE YOUNG ADULT CHRONIC PATIENT 195
sional interpretations of self and others often recede when the patient is
functioning well. However, they typically re-emerge when the patient is
under stress.
The implication of this view for the cognitive therapist is that wag-
ing a frontal cognitive assault on what appears to be a chronic-if fluc-
tuating-intrinsic impairment is unlikely to succeed. When delusional
material is presented attempts are made to translate it into consensually
validated interpersonal or intrapersonal concerns (e.g., "Sam, it seems
like you can't accept yourself as someone who gets angry." rather than
"Sam, what evidence do you have that a demon is possessing you?").
CoNCLUSION
A stage theory of group cognitive therapy with the young adult

chronic patient has been presented. I am very encouraged regarding the
potential of group cognitive therapy with this patient group. With it,
cognitive therapy appears to possess a number of advantages over tradi-
tional psychotherapy.
1. Because cognitive therapy emanates from a clearcut theory of
human functioning and behavior change, and offers specific strategies
for change, a greater isomorphism between psychotherapy process and
procedure is achieved. Conceptualizing severe psychopathology in cog-
nitive terms-specifically, detailing information processing distortions
and concomitant underlying assumptions-allows for a more precise
and operational definition of such pathology. This results in enhanced
clarity and concreteness in the actual practice· of cognitive therapy,
which are essential dimensions in the treatment of this patient group.
Payoffs include not only more vivid learning experiences in therapy, but
also laying the groundwork for the application of skills learned in thera-
py without the guidance of therapist.
2. Cognitive therapy has the technical advantage of flexibility as
well as precision. Given the extreme variability of the symptom picture,
and cognitive and behavioral deficits of the young chronic patient, it is
noteworthy that cognitive therapy passes the test of utility in that it can
be applied by people in the field working with this patient population. It
thus avoids the pitfalls of methodologically sound, but to date clinically
irrelevant, discrete social skills approaches (Wallace, Nelson, & Liber-
man, 1979) and the documented (Mosher & Keith, 1980) inadequacy of
traditional therapy approaches.
3. The structure of cognitive therapy-specifically, the emphasis on
collaboration and on the powerful role of cognitions in influencing be-
havior-is an antidote to two of the most problematic features of this

patient group: their lack of self-reliance and their tendency to disown
and project responsibility for their behavior. Cognitive therapy stands in
stark contrast to analytic and object-relations approaches which, be-
cause of their conceptual ambiguity and emphasis on transference, ap-
pear to exacerbate these tendencies. Unlike these approaches, the cogni-
tive view does not hold that ingrained ways of thinking and perceiving
will whither away as the vicissitudes of the patient-therapist relation-
ship are worked out. Rather, an active and directive approach that pro-
vides repeated learning experiences to supplant distorted thinking and
perceiving-the hallmark of cognitive therapy-is deemed necessary to
produce change in this patient group.
It also is hypothesized that group treatment holds unique advan-
tages for this patient group.
4. Some of the basic dysfunctional assumptions of this patient
group are so powerful that it may not be possible to dispute them with-
out the immediate raw data provided by the group interaction as discon-
firming evidence. Psychotic patients are not aware of believing they are
fused, persecuted, and so forth. Rather, they experience these states
directly and acutely with others. It is necessary to create some uncertain-
ty in the experiencing of these feelings and perceptions before illuminat-
ing the dysfunctional underlying assumptions.
5. There is mounting evidence (e.g., Brown, Birley, & Wing, 1972;
Leff, Hirsh, & Gaind, 1973) that the most potent triggers to psychotic
behavior are interpersonal. It is possible that the most effective learning,
and best opportunities to modify perceptions and maladaptive assump-
tions, can take place in the emotionally charged atmosphere built into
the group treatment format. Learning experiences can be linked to one
of the most crippling handicaps of this patient group; namely, their
difficulty in forming interpersonal relationships.
SUMMARY
The purpose of this chapter was to report on the application of a

group cognitive therapy approach with the young adult chronic patient.
Given the (impoverished) state of the psychotherapy art with this pa-
tient group, the intention was to experiment with a range of cognitive
therapy strategies and then observe the results. In that spirit, this chap-
ter focused on modifications in the cognitive therapy approach found
useful with this patient group. Observations were presented in the con-
text of a stage theory that emphasized the need to secure the patient's
involvement with, and socialization to, the treatment process. It is our

hope that the speculative clinical observations presented will motivate
others to attempt more rigorous study of the application of cognitive
therapy to this difficult patient group.
AcKNOWLEDGMENTS
The author is grateful to Arthur Freeman, director of training at the

Center for Cognitive Therapy in Philadelphia, for his support and help-
ful discussion of some of the issues raised in this manuscript.
REFERENCES
Anthony, W. A. A client outcome planning model for assessing psychiatric rehabilitation interven-
tions. Working paper for NIMH-sponsored conference on Outcome Research with the
Severely Mentally Disabled, Portsmouth, N.H., 1980.
sities Press, 1976.
Beck, A. T., Rush, A.]., Shaw, B. F., & Emery, G. Cognitive therapy of depression: A treatment
manual. New York: Guilford, 1979.
Beels, C. The measurement of social support in schizophrenia. Unpublished manuscript, Colum-
bia University, 1980.
Brown, G., Birley, J. L., & Wing, J. K. Influence of family life on the course of schizo-
phrenia. British Journal of Psychiatry, 1972, 121, 241-258.
Ellis, A. Requisite conditions for basic personality change. Journal of Consulting Psychology,
1959, 23, 538-540.
Emery, G., Hollon, S.D., & Bedrosian, R. D. New directions in cognitive therapy-A casebook,
New York: Guilford, 1981.
Gardner, L. H. Racial, ethnic and social class considerations in psychotherapy supervi-
sion. In A. K. Hess (Ed.), Psychotherapy supervision: Theory, research and practice. New
York: Wiley, 1980.
Glass, C. R. & Arnkoff, D. B. Thinking it through: Selected issues in cognitive assessment
and therapy. In P. C. Kendall (Ed.), Advances in cognitive-behavioral research and therapy
(Vol. 1). New York: Academic, 1981.
Heitler, J. B. Preparatory techniques in initiating expressive psychotherapy with lower-
class, unsophisticated patients. Psychological Bulletin, 1976, 83, 339-352.
Jacobs, L. I. A cognitive approach to persistent delusions. American Journal of Psychotherapy,
1980, 4, 556-563.
Leff, J. P., Hirsh, S. R., & Gaind. Life events and maintenance therapy in schizophrenic
relapse. British Journal of Psychiatry, 1973, 123, 659-660.
Lorion, R. P. Patients and therapist variables in the treatment of low-income patients.
Psychological Bulletin, 1974, 81, 334-354.
um, 1977.
Mosher, L. R., & Keith, S. J. Psychosocial treatment: Individual, group, family and com-
munity support approaches. Schizophrenia Bulletin, 1980, 6, 10-43.
Pepper, B., Kirshner, M. C., & Ryglewicz, H. The young adult chronic patient: Overview
of a population. Hospital and Community Psychiatry, 1981, 32, 463-469.
Rogers, C. R. The necessary and sufficient conditions of therapeutic personality change.
journal of Consulting Psychology, 1957, 21, 459-461.
Schwartz, S. R., & Goldfinger, S.M. The new chronic patient: Clinical characteristics of an
emerging subgroup. Hospital and Community Psychiatry, 1981, 32, 470-474.
Walen, S. R., DiGiuseppe, R., & Wessler, R. L. A practitioner's guide to rational-emotive
therapy. New York: Oxford University Press, 1980.
Wallace, C. J., Nelson, C. J., & Liberman, R. P. A review and critique of social skills
training with schizophrenic patients. Schizophrenia Bulletin, 1979, 5, 88-121.
10
Cognitive-Behavioral Treatment
of Agoraphobia in Groups
SUSAN }ASIN
INTRODUCTION
Although agoraphobia has often been viewed as a learned disorder, no

author to date has emphasized the cognitive components nor suggested
treatment that is both behavioral and cognitive.
Behavioral explanations of agoraphobia have been offered by a
number of leading theorists (Lazarus, 1966; Wolpe, 1970). Undoubtedly
the most adequate learning formulation was developed by Goldstein
and Chambless (1978). Their landmark article "Reanalysis of Agorapho-
bia" describes the core learned feature of agoraphobia as "fear of fear"
and suggests three other defining features: (1) onset during interper-
sonal conflict; (2) low self sufficiency and assertiveness; and (3) hysteri-
cal response style. Their explanation is most adequate from a behavioral
perspective and can be enhanced by greater attention to cognitive
factors.
Goldstein and Chambless (1978) contend that agoraphobics experi-
ence initial anxiety attacks in the context of interpersonal conflict, rather
than from clear-cut conditioning events like an auto accident or en-
trapment in an elevator. 1 This conflict model suggests that clients' am-
1 Pseudoagoraphobics present much like agoraphobics in that they avoid a number of
public places and/or are reluctant to venture far away from a safe person or zone. The
reasons for their restriction, however, do not involve fear of fear and may be related to
one of the following: (1) Traumatic experiences like rape that can create conditional and
generalized anxiety about travel beyond a safe zone; (2) social phobia with anxiety about
social consequences like criticism or scrutiny; (3) severe depression; (4) paranoia; (5)
borderline personality disorder.
SusAN ]AsrN • California School of Professional Psychology, 3974 Sorrento Valley Boule-
vard, San Diego, California 92121.
199
200 SUSAN }ASIN
bivalence about experiencing grief, addressing marital dissatisfaction,

resolving developmentally inappropriate dependence, or expressing an-
ger generates physical' sensations like heart palpitations, dizziness,
shortness of breath, tingling in limbs, nausea, and the like. Because
agoraphobics hold what Goldstein (Goldstein & Chambless, 1978) calls a
"hysterical response style" they fail to connect these physical anxiety
sensations to their environmental ancedents and worry instead that
symptoms will lead to some catastrophic consequence like heart attack,
passing out, or insanity. This fear of bodily sensations or fear of fear is
negatively reinforced each time an agoraphobic either avoids or flees
from a situation while experiencing an attack. In addition this fear quick-
ly generalizes, promoting progressively great~r and greater travel re-
strictions. Free-floating anxiety ensues as agoraphobics develop condi-
tioned anxiety to their own body sensations and anticipate the
possibility of additional attack. Furthermore, Goldstein and Chambless
(1978) have documented that lack of adequate assertive skills, a behav-
ioral deficit, that correlates with agoraphobia and is a significant descrip-
tive factor. The implication is that people who are unassertive and lack
self-management skills are more likely to have difficulty resolving con-
flicts and will be more anxious. 2 Thus the Goldstein and Chambless
model refers to the major learning theory components of agoraphobia
but does not emphasize cognitive deficits and distortions. The Goldstein
and Chambless explanation rests heavily on the occurence of anxiety
attacks, negative reinforcement of avoidance and generalization of effect.
However, observation indicates that something beyond anxiety at-
tacks must lead to agoraphobia. Many people who have anxiety attacks
and the opportunity to develop fear of fear do not become agoraphobic.
In order to fully understand the disorder, it would be helpful to know
what makes agoraphobics different from normals. This author believes
that the functional difference lies in agoraphobics rather unique cogni-
tive deficits and distortions. Goldstein and Chambless (1978) allude to
this, in part, when they mention "hysterical response style." Hysterical
2A smaller but still important group have been called simple agoraphobics since interper-
sonal conflict, low self-sufficiency, lack of assertiveness, and a hysterical response style
are not part of their makeup and/or are not involved in the development of their symp-
toms. The simple agoraphobic's early attacks were biochemically induced as a function of
anesthesia, hypoglycemia, street drugs, or post-operative reactions to medication. They
experience fear of fear and need to be flooded, but exploration of dynamics and modifica-
tion of characteristic coping patterns is unnecessary. For these clients, travel group alone
will be sufficient. However, the vast majority of agoraphobics need to challenge their
dysfunctional thinking, improve the ability to label and express feelings, and learn to deal
more effectively with life conflicts and stresses. The purpose of the psychotherapy group
is to learn those skills.
COGNITIVE-BEHAVIORAL TREATMENT OF AGORAPHOBIA 201
response style, the cognitive precursor to fear of fear, has been defined as
failure to connect anxiety to its true antecedents or misapprehending the
true antecedents of one's anxiety. Validating hysterical response style
has presented an interesting measurement problem. Using the Min-
nesota Multiphasic Personality Inventory (MMPI), Jasin (1981) found
elevations (group mean above 70) on the Hysteria scale for agoraphobic
males and females but since this trait has multiple descriptors it is not
clear that the elevations obtained truly reflect the intended cognitive
response. Clinical observations in hundreds of agoraphobics, however,
bear out the existence of a gap or error in the agoraphobic perceptual
system.
Nonagoraphobic clients usually respond to attacks by thinking
"What's going on to produce these symptoms?" That is, what are the
antecedents to distress. When antecedent conditions are identified,
problem solving ensues and conflicts are resolved, anger is expressed,
and so on. In contrast, agoraphobics having both poor insight, low
assertiveness and weak problem solving skills, and are obsessive about
the consequences of their discomfort. Since agoraphobics generally have
few appropriate responses they can make, it is not surprising that they
respond in a self-defeating way. Perhaps as much by default as anything
else they distort the meaning of their distress and fallaciously conclude
that some dire consequence is encroaching. Clinical interviews reveal
that those who are obsessive about heart attack often have a relative or
friend who has suffered from the condition. Ruminating about insanity
has frequently been preceded by a model who has been hospitalized for
an emotional disorder or a breakdown. Taken together the agorapho-
bics' perceptual deficits about antecedents and cognitive distortions
about consequences distinguish them from others who have anxiety
attacks. These cognitive factors seem critical to the development of the
disorder (see Figure 1).
Considering the interplay of cognitive, behavioral, and environ-
mental factors discussed, a multifaceted treatment approach is recom-
mended. In order to attain lasting improvement, treatment must attend
to both the symptoms (anxiety attacks and avoidance) and the underly-
ing causes of agoraphobia including content issues (grief, marital dy-
namics, etc.) as well as intrapersonal issues like low assertiveness, prob-
lem solving, and misperceptions. The two-stage treatment program
developed at Temple Medical School attends to these factors and has
been shown to be a highly preferred and desirable model. This chapter
excludes reference to the content issues mentioned earlier and focuses
on the development of a group model for the treatment of the symptoms
of agoraphobia and intrapersonal processes as they have been pre-
viously defined.
202 SUSAN }ASIN
Personality Variable Situational Variables Anxiety Symptoms Fear of Fear

(true antecedents)
Hysterical·style
Lack of expressiveness + Interpersonal conflict

(i.e. marriage cover,
relationship) or
unresolved grief or
Heart palpitation,
......._ rubber legs,
....,.. dizziness, nausea,
depersonalization,
Sensitization to
......._ body changes and
....,.. ruminations about
catastrophic
Low self-sufficiency medical factors etc. consequences
and assertiveness (hypoglycemia) panic (heart attack,
fainting,
Cognitive distortion craziness)
J
Increased Fear, Avoidance, Avoidance Behavior
Sensitization
Whenever a place or thing is Avoiding the near occasions
avoided, one believes even more of panic to reduce probability
in its dreadful nature of catastrophe
FIGURE 1. Agoraphobic cycle.
Many authors have espoused the psychological advantages of

group treatment. Yalom (1975) has listed 10 curative factors offered by
group psychotherapy. Of particular interest to agoraphobics are univer-
sality and cohesiveness. Almost by definition agoraphobia insures emo-
tional and social isolation and depression. Phobic anxiety and travel
restrictions often prevent what seems to be the simpler kinds of duties-
grocery shopping, PTA meetings, making deposits at the bank, and so
on. As a result, agoraphobics often feel incompetent and worthless.
Lack of sympathy from friends and relatives, who cannot possibly un-
derstand or make sense of the agoraphobics difficulties reinforces fur-
ther the agoraphobics' isolation and self-downing cognitions. In addi-
tion, agoraphobics are often connected only by their auditory umbilical
cord to neighbors and acquaintances and the telephone is no substitute
for physical contact and human warmth. Moving from this isolation into
a group of fellow sufferers and therapists who are understanding and
accepting can be a joyous experience. Another advantage to group treat-
ment is simply financial. From a practical standpoint, a group format can
be offered more inexpensively hour per hour than individual treatment.
Hopefully, this savings allows more clients to be treated and facilitates
both stages of a multifaceted treatment (referred to earlier).
TRAVEL GROUP: RATIONALE, METHODOLOGY AND PURPOSE
In the beginning stages of treatment each client is assigned to a

travel group. This group is basically an in vivo flooding group. It is
important to pause and reflect upon the choice of in vivo flooding over in
vitro flooding or desensitization. Several considerations may be re-

viewed in order to understand this decision. Although desensitization
has been used for years in the treatment of agoraphobia (Wolpe, 1970), it
has been remarkably ineffective for several reasons. First, the hierarchy
of phobic stimuli used in the procedure has been composed of places
where the client is likely to be anxious. According to the previous analy-
sis, the primary phobic cues are interoceptive. Agoraphobics are most
afraid, not of planes and lines, but the internal sensations of anxiety that
occur in such places and are imagined to lead to catastrophic conse-
quences. If desensitization were used, the appropriate hierarchy would
be made up of physiological sensations and imagined catastrophic con-
sequences not of freeways, department stores, auditoriums and so
forth. A second consideration is that even if the hierarchy were based on
an adequate behavioral analysis, agoraphobics are not easily trained to
relax. Because of their cognitive distortions most are so concerned about
losing control that relaxation (either deep muscle or chemically-induced)
becomes aversive rather than comfortable and is blocked at its earliest
stages. Third, the method of desensitization (approach the phobic situa-
tion bit by bit and back off and relax whenever discomfort arises) rein-
forces the misbelief that unpleasant physiological sensations are bad or
dangerous and should be avoided. Quite to the contrary, clients would
benefit from learning that anxiety is an important and helpful signal
(feedback from the body) that something is distressing and in need of
attention. Densensitization is incompatible with that very important
message and is therefore contraindicative. Flooding, on the other hand,
can be directed at fear of fear (rather than the bogus hierarchy of places)
and shows excellent and predictably rapid results. In addition, recent
literature helps substantiate the notion that interventions directed at the
phobia as it exists in its natural context, that is "contextual therapy," are
superior in speed and generalizability to imaginal procedures (Rach-
man, 1978). In light of these considerations in vivo over imaginal pro-
cedures and flooding over desensitization has been selected.
Flooding calls for prolonged exposure to moderate or intense anx-
iety-provoking stimuli. To accomplish this result, travel group clients
visit sites that allow them to experience internal sensations producing
moderate to intense anxiety. Clients remain in these places and focus on
the phobic stimuli that lie within them until habituation occurs. When
this procedure is repeated over and over, agoraphobics learn that anx-
iety does not drive them out of control and their inaccurate cognitions
change. They realize that at worst they will feel uncomfortable. When
these corrected perceptions are obtained, fear of fear diminishes, condi-
tioned anxiety to places diminishes, sensitization levels go down, and
frequency of panic attacks drop. It is at this point that the therapist may
204 SusAN JASIN
best begin a new series of interventions aimed at identifying and dealing

with the true antecedents or underlying causes of anxiety. This con-
stitutes the second level of treatment. In sum, providing re-educative
experience promotes more reality-based cognitions and diminishes anx-
iety and avoidance. These cognitive and behavioral changes peel away
the outer layers of the agoraphobic onion and allow access to the under-
lying causes.
The Travel Group

The size of the travel group may vary, but a range of 3 to 7 persons
with one leader and one or more helpers has consistently proven to be
quiet manageable and cost effective. Given the nature of the procedures
and resultant distress experienced by the client, it is advisable to have a
ratio of no more than 3 clients to 1 therapist or helper.
Groups may be homogeneous or heterogeneous; however, it may
be most effective to cluster clients who share similar educational and
socioeconomic backgrounds rather than those who are at a similar stage
of recovery. "Seeding" the group with more advanced clients provides
beginners in treatment a coping model as well as a source of inspiration.
The helpers provided are trained members of the staff and may be
either psychological or psychiatric interns or former agoraphobics who
have completed treatment. Helpers without either of these two back-
grounds often are not well received, as clients perceive them as not
understanding. Perhaps because they have "been there" former clients,
who have been trained adequately, seem to be the most trusted and
most engaging therapeutic assistants. The preparation they are given
consits of: (1) their own experience and recovery; (2) a thorough techni-
cal orientation to the two levels of the program; (3) a series of helper
workshops where the helpers role play the therapist; and (4) several
months of apprenticeship with experienced leaders in a number of dif-
ferent groups. In this apprenticeship period, the helpers practice coach-
ing clients in the use of coping strategies and gather on-the-spot feed-
back and supervision from the group leader. Although it is tempting to
assign paraprofessionals or newly recovered clients directly to the role of
helper, this procedure can and often does lead to bewilderment, distress
and, at best, retarded progress for the client.
Frequency and Duration of Groups

Several options exist for scheduling travel groups. Massed practice
alone (e.g., a two-week intensive program) produces rapid, visible pro-
gress that may both generalize poorly to the clients' home setting and
lack durability over time. Spaced practice alone (e.g. weekly sessions)
generally yields less dramatic improvement and less motivation for con-
tinuation. In its favor, spaced practice produces more durable change
and generalizability of results when the time between sessions is used to
complete travel homework assignments. A combination of massed and
spaced sessions may be the best format. A two-week daily program
followed up by weekly meetings allows the client "to get off to a flying
start" by seeing immediate and dramatic improvements and also pro-
moting permanent change by incorporating coping strategies and ex-
posure methods into the client's daily routine.
In addition to the spacing of sessions, decisions must be made as to
the length of each session. Following the guidelines for flooding, a
group meeting must be long enough to provide a minimum of 1V2 hours
of exposure to the phobic stimuli so that habituation can occur (Levis,
1980). Since the structure of the group (see "Structure and Format"
section) includes homework review as well as post-exposure processing,
a minimum of three hours is recommended. Shorter groups are marked-
ly less effective and longer groups show increased habituation that
seems to reach the point of diminishing returns after six hours.
Structure and Format
Prior to the first group meeting, it is desirable, though not neces-

sary, for the client to meet individually once or twice with her3 primary
therapist. During that time the therapist can begin to establish rapport
and build trust while getting a full account of the client's symptoms and
fears. Initially, the use of the Severity of Agoraphobic Scale can provide
a measure of agoraphobic avoidance (Chambless, Caputo, & Jasin,
1982). Once a description of the presenting complaint has been ob-
tained, short and long-term goals may be set and the initial in vivo
training can begin. (It is also worth noting that the Severity of Agora-
phobic Scale can be used post-treatment in order to verify results.)
After this pretraining and during the first group meeting, an hour is
spent on introductions. Each client tells her story-how the symptoms
began and developed, and what her limitations and fears are at the
present. In the second hour, the primary therapist gives a non-technical
explanation of the development and maintenance of agoraphobia. Since
most clients and their families view agoraphobic behavior as sick, weak,
3feminine pronouns are used when referring to the agoraphobic client (1) for simplicity;
and (2) at present approximately 80% of agoraphobic clients reporting for treatment are
female. As sex-role persecutions relax more male agoraphobics will probably report for
treatment.
206 SusAN ]ASIN
z ;If out of control
/
/
/
/
/
/
/ /C The worst is still
,/ only discomfort
l
Intensity of
psysiological
fear response
habituation
process
A {possible score of 1)
Escape
TIME
FIGURE 2. Panic/anxiety attacks: habituation versus escape.
or at best stupid, it is important to correct these inaccurate perceptions

immediately. Such judgmental explanations of agoraphobia only reduce
further the self-esteem, perceived self-efficacy, and motivation of the
already depressed and fearful agoraphobic. In place of a pathology
model, a behavioral anlaysis is given. Emphasis is placed upon the
accidental nature of the cognitive and behavioral learnings that have led
the client to her present set of maladaptive thoughts and habits. Refer-
ence is made to cognitive and behavioral deficits as predisposing factors,
classical conditioning of anxiety to neutral places, adventitious rein-
forcement of avoidance behavior and so on. These explanations lack the
judgmental quality of the pathology model and help the client to begin
to gather some vestige of self-esteem. In addition, a cognitive-behavioral
orientation allows the client to modify her thoughts about treatment-to
see it as straightforward retraining rather than the mysterious task of
"sanitizing one's psyche."
After the first wave of questions have been answered, the leader
introduces the rationale and the design of the flooding model as well as
the need for cognitive coping strategies to promote habituation. Figure 2
depicting panic-anxiety attacks may be helpful in explaining the impor-
tance of habituation versus escape. An explanation such as the following
may be given to the group concerning Figure 2.
At Point A, you begin to experience the first signs of mounting anxiety,
perhaps tingling in the arms and legs, and nausea. As time passes, the level
of distress increases and at Point B you feel heart palpitations, dizziness,

sweating, shaking, and "jelly legs." Uncomfortable and frightened, you
think about how your sensations will continue to worsen until you go com-
pletely out of control. You worry that your distress will escalate and you
picture yourself losing control, having a heart attack, or passing out. As a
result of this catastrophic thinking and imagery, you terminate the upward
spiral of anxiety, at first by distraction and finally by escape. Your flight is
negatively reinforced because it stops your discomfort. You learn to escape
and eventually avoid simply because it feels better than suffering discomfort,
terror, and the chance to go crazy, faint, or die. At the same time you learn to
be anxious and run more and more frequently. You also learn to fear the
place where you have had the attack. This place becomes frightening because
of its association with past attacks and just being there in the future will be
enough to bring on another one. What you need to learn instead is that your
attacks can go to a peak of panic and great discomfort (see Point C) but no
further. Unless you persist in picturing yourself dying or going out of control,
once your anxiety reaches its peak your body's natural adaptation will take
over and you will begin to feel better. As time passes you will adapt more
and more and feel progressively less anxious and more comfortable. After
some time the attack will end all by itself. I know you don't believe me.
That's okay. I'm not asking you to. You need to know, not because I have
told you, but from experience, that the worst is still only discomfort. The only
way to know and trust the safety of adaptation is to block avoidance and
escape and to experience a full panic attack again and again until you can
believe for yourself that you won't go crazy.
This rationale for flooding is made available to the client in the first
group meeting, as well as on subsequent occasions.
In the second group meeting, the client is acquainted with a coping
technique that will help her manage anxiety both during flooding ses-
sions and on her own. This method if called focusing and it is explained,
role played, and practiced in a short in vivo exposure module. Although
only one of several strategies, focusing, like other strategies, keeps the
agoraphobic exposed to the fearful internal sensations so that over time,
fear of fear dissipates. Although simple in essence, many clients new to
treatment are so afraid of their symptoms that they cannot identify or
describe them. Many others are so fearful that they cannot bear to expe-
rience their symptoms for more than a few seconds before some form of
distraction like talking, singing, smoking, or ruminating takes over. The
first coping technique is simple to "be inside your body" for as long as
you can stand it while focusing on all unpleasant sensations, describing
them verbally to the coach.
The therapist may first model focusing, then ask the client to re-
enact a typical attack. The therapist or coach sets the stage (department
store, checkout line, etc.) than asks the client to begin describing out
loud the body sensations that would be likely to occur. As the role play
208 SUSAN JASIN
begins, she is asked to "go through her body" reporting all current
symptoms. She is first asked to focus on how her head feels. Does she
have blurred vision, headache or pressure, dizziness, depersonaliza-
tion, dry mouth, a lump in the throat, or some other form of discomfort?
Reports such as, "I feel like I'm going to choke" or "I know that I am
going to pass out" are future-oriented and catastrophic. When such a
remark is made, the client is asked, "How does it feel right now? Please
describe the lump in your throat. What are the exact dimensions? De-
scribe the dizziness. Does your head feel like it's spinning or floating?"
Next she is asked to move her attention down her body, reporting
anything out of the ordinary such as chest pressure, heaviness, hollow-
ness, palpitations, tachycardia, knotted or fluttery stomach, nausea,
blood racing or curdling. Again, futuristic catastrophic statements like
"What if I suffocate?" or "What if I have a stroke?" must be modified
immediately by asking "Please, what are you feeling right now." A
client who is allowed to continue catastrophizing will have a virtually
impossible time habituating. Catastrophizing feeds anxiety-not just for
agoraphobics--but for all of us. A later section reports other more con-
frontive strategies for anxiety reduction. In the beginning of treatment,
however, simply focusing on immediate body sensations will begin to
decondition the agoraphobic's fear of fear.
After the client role plays "going through her body," she is asked to
pick only one symptom, the most frightening, and stay focused on it,
describing it aloud if necessary, until her fear of it or the sensation itself
subsides. Optimally, she stays focused on the experience until it is no
longer frightening and then continues to focus until the experience goes
beyond extinction to boredom. Often as one's body sensation dimin-
ishes another will peak, causing the agoraphobic renewed distress.
Again, she is asked to simply stay with it. Although distractions and
obsessions will automatically recur, the skilled coach repeatedly re-
focuses the client on current sensations. This method not only hastens
habituation and extinction of fear of fear, but also gives the client a task
or strategy to combat helplessness. It provides a semblance of control
much like pointing in the direction that the traffic is moving while at the
same time commanding "Go that way!"
In order to offset the discomfort of focusing, a self-support method
called grounding is also taught. This Gestalt technique involves attending
to non-phobic immediate stimuli, both outside and inside the client's
body, especially those that promote the feeling of stability and connec-
tedness. For example, the agoraphobic can begin by describing her exact
location. "Right now I am halfway up the bridge on Route 42 headed
toward Center City. I see the car lights coming toward me. I am aware of
the Schlitz sign to my right and the field to my left. The sky is clear and
there are stars overhead. The traffic is light and mostly in the opposite
direction." Next the client describes and feels the supports within and
against her body. "I feel my buttocks and back pressing against the car
seat. The seat feels solid and a little lumpy and I also feel my hands
wrapped around the steering wheel. It is cool and has ridges. I am aware
of my own backbone as well and that it is supporting my trunk. It feels
solid even though I am trembling." Grounding alternates with focusing
so that in this example the client will again describe internal phobic
stimuli saying "I am aware of the shaking in my arms and legs, my heart
is racing. I can feel sweat under my arms and on my palms. My legs are
weak and rubbery." These two descriptions lock the client into the pre-
sent, insure contact with the true phobic stimuli (internal sensations),
and provide appropriate counter-conditioning agents. Though simple,
grounding and focusing are incredibly effective.
After several role plays, a short trip outside the group room is made
to do some real focusing and grounding. Guided individually by thera-
pists or helpers, each agoraphobic practices focusing in a minimally
threatening situation, perhaps walking a block from the building, climb-
ing the stairs, or taking short elevator trips, and grounding to the sup-
ports in that environment. At this time, as always, success is defined as
having symptoms and practicing effective coping. Clients are told that
once they master these techniques they will be able to travel freely,
though not necessarily comfortably. They also know that ultimately the
elimination of their excessive symptomology can be accomplished only
when the underlying reasons for their anxiety have been identified and
eliminated.
Once focusing and grounding have been mastered and in the suc-
ceeding sessions, clients learn important cognitive strategies to diminish
catastrophizing and further reduce anxiety. Among these are echoing or
repeating a catastrophic self-statement. Catastrophic thinking includes
statements such as "What if this time I really flip out?" "What if I pass
out and no one cares for me?" "What if my heart can't take the strain
and I have a heart attack?" Several steps are used to attack this kind of
maladaptive thinking. First, the client is encouraged to pay attention to
her futuristic, horrific thoughts and their subsequent effects. To facilitate
the process, the agoraphobic may be asked to think out loud, having her
coach identify the maladaptive self-sentences. Then she may be asked to
repeat each one five times, noting how her anxiety level varies as a
result. It soon becomes clear that this thinking is hurtful because it
intensifies her anxiety, gets her out of the "here and now," slows habit-
uation, and thrusts her into future traumas she cannot possibly deal
210 SusAN }ASIN
with in the present. Since each of us can only deal with what is presently
happening, catastrophizing makes an agoraphobic virtually powerless
and defenseless. It is suggested that if an individual can deal with what
is here now and now and now and now, the future will be handled.
After recognizing that catastrophizing is a foundation for increased
anxiety and ultimate failure, the client tries out active ways to challenge
it. They include first of all questioning the data and rational self-dialogue
(Beck, 1979). Examples of this include:
I know it feels like I can't get enough air, but I'm really just hyperventilating.
Although it feels like I am going crazy I have felt this way before and I have
not been locked up yet.
I know it feels like I am going to have a heart attack, but the doctor says my
heart is fine and that I am in no danger when I get palpitations.
A second cognitive technique is verbal or visual thought stopping-

interrupting catastrophisizing by thinking the word "stop", then snap-
ping a rubber band around the wrist to eliminate destructive self-talk.
Other clients visually empty their head of thoughts by putting them in a
"mental garbage can". Third, the self instructional procedures sug-
gested by Meichenbaum can be adapted (Meichenbaum, 1977). Clients
are encouraged to develop and test coping statements that are self-
instructional in nature. Figure 3 portrays a list developed by one such
client. 4 It is important to insure that clients do not use these cognitive
strategies as avoidance but rather interpose them with focusing on their
internal phobia stimuli. Last of all paradoxical intention is an advanced
cognitive strategy that may be taught after four or more flooding ses-
sions to those who are particularly courageous and/or have a good sense
of humor. Specifically, the client is asked to make the most frightening
symptom worse, not by catastrophizing, but by focusing on it and talk-
ing to it. "OK heart, let's go, beat faster! Come on pop out of my chest,
faster, faster! I dare you. Let's go over the top. Give me your worst!
Come on, pass out! Let's go. Get dizzier. Head be a balloon. Float to the
ceiling." The impact of this cognitive strategy is enormous as it displaces
the catastrophizing with a kind of bravado that is not only functional but
also amusing-and who can forget what an effective counter condition-
ing agent humor is! After a full description of these procedures is made
and questions have been answered, clients rehearse by working in
dyads, each playing the role of both client and coach. Therapists circu-
4A special thanks to Carmen G. for allowing publication of her personal list.

Stay with the feeling-don't fight it.

The worst that could happen is discomfort.
I've lived through this before and I'll make it this time.
It only feels threatening.
It will pass.
The best thing that can happen is when it's over I won't be as
afraid of it next time!
I only feel out of control:
Than a positive-l'm driving OK. I'm walking OK
By letting go I am in control.
I may feel out of control, but I'm in control.
The way to get out of this is to go thru it.
I am not going to die.
I have done this before and I'm going to do it again and nothing
bad will happen.
The worst thing that can happen is I'll panic (and that hasn't hurt
me yet).
The best thing that can happen is that I'll be one step closer to
recovery.
I will make it home. I've always made it home.
I can do this and I will do this because I want to do this.
If I have to feel high symptoms to get better, I will.
Feeling the symptoms is good-it means I am working toward
recovery.
I'll never get better if I keep running from the symptoms.
I am getting better.
I am a brave, hard working person and I'm proud of me.
FIGURE 3. Cognitive coping strategies designed by agoraphobics.
late among the dyads giving feedback and reinforcement and standing
in as coach or client whenever necessary.
In the second half of the practice session, the group once again
visits minimally distressing locations and practices using coping strat-
egies in vivo. Upon the return to the therapy room, each client has an
opportunity to "process" what has happened-to review her experience
while traveling. This processing module is exceptionally important as it
allows clients to clarify what worked for them and what did not. In the
midst of a panic attack it is difficult, if not impossible, to get a sense of
212 SusAN JAsiN
what is going on. Processing afterward affords the opportunity to step

back and sort out what has gone on and also reinforces the pattern of
planned strategies for dealing with panic rather than blind flight. Recall
as well, that the definition for success has changed from comfort and
skillful avoidance to coping effectively with symptoms. This too, is a
cognitive shift of prime importance as it activates avoiders, turning them
into seekers.
The last work in the group meeting involves each client, with the
help of the leader, planning homework to consolidate gains. Homework
may consist of repeating the same travel task without the support of a
therapist. Another support person may be used or the client may make
an attempt to go it alone. Generally it is important not to ask too much
since a victorious client in a group often cowers at the thought of doing
exactly the same task without "an expert" along or in the vicinity. The
laws of shaping are followed-little steps and big rewards. Overlearning
or extinction beyond zero is another useful guide. The client may be
asked to practice going to shopping malls until she is bored before she
shifts to another, more difficult task. Always program for success. Fig-
ure 4 is a sample homework sheet that encourages agoraphobics to
develop a written plan of action, self-generated feedback, and a perma-
nent record of improvement.
Later meetings follow a different schedule agenda. The first forty-
five minutes is spent going over homework assignments to further
shape risk-taking, practice, and the effective use of coping strategies.
Group- as well as self-reinforcement is taught. The topics of secondary
gain, self-esteem and independence are developed. Figure 5 provides a
data keeping sheet on which clients may record anxiety episodes and
their antecedents. These sheets allow the client to begin developing
"insight" into the onset of their discomfort. They are either discussed in
the travel group or taken with the client into individual or group psycho-
therapy. The second Jl/2 hours of the session are devoted to exposure.
Subgroups may be formed so that each client can work on becoming
accustomed to a variety of places while reducing her sensitivity and fear
of internal sensations.
Included in group activities are trips to shopping locales, bridges,
elevators, theatres, open spaces and so on-doing almost anything that
the client is agoraphobically afraid to do. For advanced groups, long
train or car trips, even airplane flights, as well as the ultimate agorapho-
bic experience, an amusement park, may be included.
Following. travel, the group reconvenes so that members can "pro-
cess" their experience, laugh, congratulate each other, draw support
when they need it, and finally plan their upcoming homework. Over
DATE NAME
Task 1 Task 2 Task 3 Task 4 Task 5
Goal
Mode of transport
Time of day/night
Companion (s)
Medication: before,
during task
Distance from home

or other challenge
involved
Emotional/physical
reactions
Rewards and
satisfactions
experienced
Additional comments
Discomfort score
(0-5) at end of task
FIGURE 4. Homework sheet.

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0 Q)
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E
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(.)
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....
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I
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FIGURE 5. Client record of panic attacks.
216 SUSAN JASIN
time, the therapist's role is reduced as clients need less and less coaching
and take the initiative in planning group activities. As this happens, the
client surely experiences herself as more effective and competent, as
well as less phobic. At the end of each 5 or 10 week block of groups, each
client's stated goals are evaluated. New goals are set when old ones are
attained. In order to prompt group leader attention to a number of
preferred interventions, a Travel Group Leader Checklist has been im-
provised and is included in Figure 6.
Of special note is that skillfully coached flooding may provoke
important visual, verbal, and kinesthetic .recollections. These memories
may relate to relevant historical or current dynamics. Often at the very
peak of intense feelings, one may ask the client "In what other situa-
tions do you recall having felt like this?" An immediate response might
be "The night my father died" or "When I am with my husband I feel
just this way-trapped." Another intervention is to ask the client to
experience what emotion she feels "beneath" the fear. Often the thera-
pist can readily see that intense anger, grief, or loneliness are operating.
These strong affective states terrify most agoraphobics by nature of their
sheer intensity. A fairly significant portion of agoraphobics, perhaps
20-30%, have unresolved grief as the true antecedent to their distress.
Perhaps another 20-30% are angry and confused about their relation-
ships and their resultant ambivalence precipitates distress that they do
not connect to an interpersonal cause. These kinds of data are certainly
grist for the therapeutic mill and should be recapitulated in the psycho-
therapy sessions.
Psychotherapy Group
Prior to treatment, most agoraphobics believe that their symptoms
come from "out of the blue" and probably reflect some underlying
weakness or craziness. In the psychotherapy group, this belief is sup-
planted by the more accurate notion that excessive anxiety symptoms5
often mask other deeper and more frightening emotions. The group
5The adjective "excessive" is used to imply that some anxiety symptoms are normal and
adaptive. They are signals from our bodies that we are experiencing distress and should
take a look at the factors that cause it. Hence, anxiety in small doses is an important cue to
scan the environment (inside and outside) to look for an adaptive change or instrumental
response. Unfortunately, most agoraphobics envision cure as life without anxiety of
symptoms. Even some that are "cured" refuse to recognize the fact because they "still
have symptoms." To correct this misconception, clarification of the utility of anxiety (in
appropriate amounts) must be made repeatedly.
LEADERS' NAME _ __ DATE - - - -
D Homework reports for each client and social rein-

forcement.
D Instruction on how to better cope with difficulties

encountered in the last week.
Note here questions you had trouble answering or

difficulties you had trouble resolving:
D Work on client self-reinforcement.
D Work on countering the client's tendency to minimize

accomplishment.
D Developing individual task(s) for travel segment.
D Coaching in the use of paradoxical intention.
D Repeated restatement of Rule 1: Don't turn back

when you are feeling panicky. Stop and use the
technique or just wait until you feel better-then
proceed or return home.
D Report on successes of the day.
D Development of next weeks homework.
FrcuRE 6. Checklist and feedback sheet for travel group leaders.
exists so that clients experience contact and assimilation of interpersonal

issues rather than interruption and inhibition. The group begins with
exercises to increase sensory and affective awareness. Members are
guided through a process that begins with experiencing basic sensations
and emotions and ends ideally with expression and need satisfaction.
218 SusAN }ASIN
Then, just as in a travel group, clients learn to stay with their feelings
rather than utilizing distraction and intellectualization to diffuse them.
The dysfunctional belief that feelings are dangerous diminishes quickly
with repetitive group training and group practice.
As the client's fear of anxiety is reduced she should begin to make
connections between her discomfort, antecedent events and other kinds
of affect. For between-session practice in making these connections, the
record sheet depicted in Figure 5 is suggested. As this progresses ex-
pressiveness training can begin. The client is taught not only that her
feelings are all right but that she has the basic human right to experience
and express them. She is trained to use expressions that are clear, direct
and appropriate with regard to the social context and the level of inti-
macy needed in the situation.
Coupled with assertiveness/expressiveness training, the therapist
continues to work on changing the agoraphobics hysterical style. Meth-
odologically, a therapist makes every attempt to work with the affect
that arises in the session rather than talking about past feelings and
problems. Although the exploration of past traumas and conflicts may
be necessary, the emphasis is on coping with current feelings and diffi-
culties even if they arise in historical context. Inevitably, this experiential
modality produces better relearning than interventions made on an in-
tellectual level.
Two of the more common feelins that arise in the psychotherapy
group are anger and grief. Even though it may appear that unresolved
grief could be handled in a group, individual flooding sessions are
somewhat more effective as they provide massed extinction trials. This
work should be scheduled in addition to or in place of group psycho-
therapy. On the other hand, anger is an affect that is more appropriate
to psychotherapy groups. If anger is current, but primarily the result of
past or cumulative turmoil, it can be productive to express anger in the
session by reliving old scenes. A discussion of basic human rights may
be helpful and guidelines for acting assertively rather than aggressively
or passively can be provided. Role playing, expressiveness, and using
feedback from the group and its leader further help the client to develop
confidence and expertise in assertiveness (see Lange & Jakubowski,
1978). As Fodor (1974) suggests female agoraphobics are often tradi-
tionally feminine and rigidly sex typed. They often put others first and
themselves last, as many women have been taught to do. Many of their
emotional and physical needs remain unfulfilled as they passively wait
for others to be as giving to them as they are to others. Resentment,
depression, restricted activity, and interest, as well as low self-esteem,
frequently follow. Improving one's ability to cope not only involves
expressing feelings, but also doing things about those feelings and for
oneself. This "enlightened self-interest" as Ellis (1962) calls it must be
shaped carefully. It may begin with the simple task of taking one hour a
week to do something for oneself.
Although the treatment just described is composed of two parts
which naturally complement each other, it would be misleading to sug-
gest that improvement is linear. An important and complicating factor is
the role of the significant other and the effect of symptom reduction on
the agoraphobic's family system. As the identified client becomes more
mobile and expressive, the significant others in her life react with sur-
prise, pleasure, and often a good deal of discomfort. Understanding of
this diversity of reactions is easier if one thinks of the agoraphobic family
as a system: Because of her "illness," others have learned to protect,
accompany, support, and in many ways, accommodate the behavioral
and emotional limitations and difficulties of the agoraphobic. At least
one significant other has served as a "phobic companion," a personal
representative of safety who travels with the client by promising to care
for her if she should be overwhelmed by an attack. This role is time-
consuming, inconvenient, and demands a great deal of patience and
effort. In addition to his or her caretaking duties, the phobic companion
generally has accepted the role of therapist. By the time the client has
entered therapy, the phobic companion has tried a variety of common-
sense treatment techniques such as reasoning, joking, and finally, pres-
suring the phobic to push through her fear. When these methods fail to
work and the client seeks professional help, the phobic companion or
"therapist" feels displaced and diminished. As the agoraphobic im-
proves, the significant other experiences elation as well as confusing and
contradictory feelings. Most experience some sense of failure for not
having brought about a cure themselves. Often the companion is angry
at the therapist or program for displacing him and fears that the agora-
phobic's growing independence ultimately may lead to disruptive
changes in their relationship and the family unit (e.g. fear of extramarital
affairs, divorce, etc.). Sabotaging the therapist's effort is a common re-
sult of the significant other's mixed feelings.
CONCLUSION
As self-care and assertiveness skills develop and travel anxiety and

panic attacks subside clients approach the seemingly unresolvable con-
flicts in their lives. Many join a couples group or enter individual thera-
py. Some eventually separate or divorce. Almost all can become more
220 SUSAN }ASIN
autonomous, fully functioning adults. As these personality changes take

place, the client's mobility continues to improve quite spontaneously. It
would seem that the client's ability to cope with life enhances her per-
ceived self-competancy and self-esteem, and allows her to feel more in
control, rather than fearful of going out of control. In addition, as her
independence grows, so does her ability to separate from the program.
A number of recovered agoraphobics, perhaps as a function of their
special sensitivity to separation, do not leave. They stay with the pro-
gram to become office aides, helpers, travel group leaders, even psy-
chologists. They seem eager to share with others what they have gained
through therapy. They may form a fairly extensive volunteer staff that
helps provide the kind of coverage necessary to make superior two-
phase treatment of agoraphobic possible.
REFERENCES
Beck, A. T. Cognitive therapy of depression. New York: Guilford Press, 1979.

Chambless, D. L., & Goldstein, A. J. The treatment of agoraphobia. In A. Goldstein & E.
Foa (Eds.) Handbook of behavioral interventions. New York: Wiley, 1980.
Chambless, D. L., Caputo, G. C., &Jasin, S. E. The Severity of Agoraphobia Scale. Manuscript
submitted for publication, 1983. (Available from D. Chambless, Dept. of Psychology,
American University, Washington, D.C. 20016.)
Ellis, A. Reason and emotion in psychotherapy. New York: Stuart, 1962.
Fodor, I. G. The phobic syndrome in women: Implications for treatment. In V. Franks & V.
Burtle (Eds.), Women in therapy. New York: Bruner/Maze!, 1974.
Goldstein, A. J., & Chambless, D. L. A reanalysis of agoraphobia. Behavior Therapy, 1978,
9, 47-59.
Jasin, S. E. A comparison of agoraphobics, anxiety neurotics and depressive neurotics using the
MMPI and Beck Depression Inventory. Unpublished doctoral dissertation, Temple Uni-
versity, 1981.
Lange, A. J., & Jakubowski, P. Responsible assertive behavior. Champaign, Ill. :Research
Press, 1976.
Lazarus, A. A. Broad-spectrum behavior therapy and the treatment of agoraphobia.Behav-
ior Research and Therapy, 1966, 4, 95-97.
Levis, D. J. Implementing the technique of implosive therapy. In A. Goldstein & E. Foa
(Eds.), Handbook of behavioral interventions. New York: Wiley, 1980.
um Press, 1977.
Rachman, S. J. Fear and courage. San Francisco: W. H. Freeman, 1978.
Wolpe, J. W. Unravelling the antecedents of an agoraphobic reaction: A transcript. Behavior
Research and Therapy, 1970, 1, 259-264.
Yalom, I. D. The theory and practice of group psychotherapy. New York: Basic Books, 1975.
11
Sexual Enhancement Groups
for Women
SusAN R. WALEN AND JANET L. WoLFE
Despite the so-called sexual revolution, large numbers of sexually con-

fused and frustrated women still abound. Kinsey (Kinsey, Pomeroy,
Martin, & Gebhard, 1953), Hunt (1974), and Hite (1976), arriving at
strikingly similar figures, report that approximately 10% of American
women never experience orgasm and that well over half of sexually
active women do not regularly reach orgasm in their coital experiences.
The woman who sought treatment often has gone to professionals who,
following Freudian tradition, questioned her feminine identification or
tried to help her transfer her erotic sensitivity from her sexual organ, the
clitoris, to her vaginal canal-usually, in the process, exacerbating her
problem.
Masters and Johnson's (1970) pioneering work in the development
of behaviorally-oriented treatment (which viewed orgasmic dysfunction
as due largely to faulty learning rather than as a sign of severe neurosis),
was more on the mark but frequently required costly conjoint therapy
and a cooperating partner, thus leaving a large percentage of women out
in the cold. In the wake of an alleged sexual revolution-which has left
many with the impression that everyone is having (or should be having)
a sexual ball-the woman who does not see herself as fitting into the
popular stereotype of the sexually emancipated woman often is left with
increased feelings of despair. As one client put it: "I think I should be
oozing and juicing all over the place, having multiple orgasms. I felt
better a few years ago, when I thought I was supposed to be bored."
SUSAN R. WALEN • Department of Psychology, Towson State Uni_versity, Towson, Mary-

land 21204. }ANET L. WoLFE • Institute for Rational Living, 45 East 65th Street, New York,
New York 10021.
221
222 SUSAN R. WALEN AND JANET L. WOLFE
Time-limited all-women's sexual enhancement groups and pre-

orgasmic groups have provided a powerful demonstration of how effec-
tively and efficiently sex therapy can be done when the appropriate
learning conditions are provided. Barbach (1974) has reported the most
extensive data on group treatment of preorgasmic women. Of 83 women
treated, 91.6% learned to reach orgasm with masturbation, and a major-
ity were able to generalize their sexual skills to partner situations with-
out specific programming for such transfer. Heinrich (1976) reports that
100% of 15 women became orgasmic with masturbation within 10 ses-
sions; at two-month follow-up, 13 of the women were orgasmic in part-
ner sex, additionally reporting increased frequency and pleasure in sex-
ual activity. Lieblum and Eisner-Hershfield (1977) found an increased
frequency of masturbation and orgasmic response, increased comfort in
discussing sex, in body exploration, and in the use of vibrators as a
function of group treatment. Schneidman and McGuire (1976) reported
that 70% of formerly nonorgasmic women under age 35 learned to reach
orgasm with self or partner manual stimulation in a 10-week group.
Although only 40% of the women over 35 accomplished this goal within
the 10 weeks, 60% had done so by the 6-month follow-up. Research by
Barbach (1974), Heinrich (1976), Kuriansky, Sharpe, and O'Connor
(1976) has demonstrated that women who participate in preorgasmic
groups feel far better about their bodies and feel they have better control
over their lives after therapy. As Barbach (1980) indicates,
though relatively few transfer their orgasmic ability to relationships before
the end of the group, most do so within seven or eight months after the
sessions have ended, without any further therapy. This result suggests that
the women do more than solve a narrowly-focused problem; they learn
concepts and tools for approaching a broad range of problems, and can
utilize these techniques at a later date.
In addition to increased orgasmic responsiveness, other results that are

consistently reported to occur as a function of group treatment are re-
duction of sexual anxiety, reduction of sexual inhibitions, enhanced
body image, increased self-acceptance, increased confidence in the abil-
ity to feel pleasurable and sensual feelings, and increased desire for sex.
The effectiveness of individual and conjoint sex therapy for women
with sexual dysfunctions has been well documented (Walen, Hauser-
man, & Lavin, 1977). Behavior therapists (Brady, 1966; Chapman, 1968;
Lazarus, 1963; Madsen & Ullman, 1967; Wolpe, 1969) have reported 85%
to 100% success in the individual treatment of female orgasmic dysfunc-
tions. Individual therapy results from nonbehaviorally oriented thera-
pists have been far less well documented. In a study of 61 partially or
totally "frigid" women treated four times a week in psychoanalytically-
SEXUAL ENHANCEMENT GROUPS FOR WOMEN 223
oriented therapy for a minimum of two years, 25% of the cases were
cured (O'Connor & Stern, 1972). In a sample that excluded women
without partners and couples without serious marital or psychological
difficulties, Masters and Johnson (1970), following a conjoint behavioral
treatment model, found that 83.4% of a group of 193 anorgasmic women
became orgasmic after two weeks of therapy. Although research directly
comparing the efficacy of individual versus group treatment is not avail-
able, our clinical experience suggests that group treatment is to be pre-
ferred. In addition to being less costly than individual therapy, and not
requiring a cooperating partner, the group format is more efficient, en-
hances motivation, and generally seems to provide a context most ide-
ally suited to women's unlearning old maladaptive attitudes, feelings,
and behaviors, and supplanting them with newer and more adaptive
ones.
A major therapeutic element that has been identified in group ther-
apy is the relief from self-blame and anxiety that comes from the discov-
ery of the group members' shared suffering and the acceptance by oth-
ers despite one's flaws (Yalom, 1970). All-women's groups seem to offer
ingredients that help provide their members with an especially powerful
corrective emotional experience and an especially facilitative learning
environment. A major ingredient in this is the increased communica-
tional freedom that the same-sexed group seems to provide. Meador,
Solomon, and Bowen (1972) found that "women together talk differ-
ently from the way they do in the presence of men. The cultural condi-
tioning which most women have assimilated rises to the fore if only one
man is present" (p. 338).
An important influence in women's difficulties in sexual enjoyment
has been their sex role scripting that has taught them to be passive,
dependent, to value themselves and their bodies largely on the basis of
their ability to lure and secure a male, and to rely on a male to come
along and light their orgasmic fire. The all-women's SE:xuality group is
seen as providing a place where a woman can come and, shutting out
the psychosocial influences of her past, enter a supportive and protec-
tive place where she can discuss, learn, and practice an entirely different
set of attitudes about herself and her sexuality. In the climate of warmth,
support, playfulness, and caring that rapidly occurs in the women's
group, a powerful and at times almost magical appearing development
of abilities occurs. A woman can experience her own power as a person,
develop a more positive relationship with herself and her body, and take
responsibility for her orgasms.
Between sessions, when she is doing her masturbatory homework,
the group member is comforted at the thought that there are at least six
224 SusAN R. WALEN AND }ANET L. WoLFE
other women in her community who are also masturbating. Back in the
group, she is provided with a set of reinforcement contingencies that are
often the reverse of those in the "outside world." In contrast to the
impatience or blame she may have gotten from her spouse or lover, she
receives hugs and cheers from other group members for the first tingle
in her vulva, or for her first stumbling attempts at asserting herself. A
plain-looking unpartnered woman in her 50s-often not seen as a sexual
person on the outside (by others and herself)-experiences herself for
the first time as an envied sexpot and is complimented on her new
"glow" when she reports to the group her sexual experimentation with
water-massagers and new masturbation positions. Group members are
reinforced and supported in a new belief system that is the basis of their
sexual self-determination-that they have a right to get satisfaction for
their own wants (sexual and nonsexual), rather than merely taking care
of others, and that they are in charge of their lives and their sexuality.
And finally, in a group whose members all have the same kinds of
genitals and essentially the same long-time freeze on sexual discussion,
they receive much-needed practice in sharing sexual feelings and com-
municating about sex that will become the bridge to their communicat-
ing these feelings to their partners with greater facility and comfort.
A COGNITIVE-BEHAVIORAL GROUP MODEL
A variety of styles of women's groups have been reported in the

literature. Often, however, little detail about the structure or format of
the groups is given, so that a therapist may not have very clear guide-
lines for conducting them. It is our purpose in this chapter to describe in
some detail how we conduct our own women's groups and to outline
procedures for dealing with typical kinds of problems. Since an impor-
tant ingredient in the groups is dealing with problems in a flexible,
individualized manner, it is recommended that the chapter be used not
as a rigid blueprint for how one must run the group, but rather as a set
of suggestions on procedures and issues emerging from the groups we
have conducted. Although research has not yet been done dismantling
the effective components of the treatment, it is our belief that our groups
are most distinguishable from many of those run by other professionals
because of their heavy focus not merely on behavior change or skill
acquisition through the use of sex therapy techniques, but on teaching a
more expanded set of skills for restructuring the attitudes and cognitions
that are seen as underlying sexual dysfunctioning and attendant emo-
tional distress. It is this teaching of a general disturbance-combatting
cognitive self-help approach that accounts for what appears to be our

unusually rapid elimination of the target problem (90 to 100% of the
women in our groups orgasm in only six two-hour sessions) and for the
heavy generalization to other areas of the women's lives (Wolfe, 1976).
The goals of the group encompass a broad range of cognitive and
behavioral changes:
1. Becoming more comfortable talking about sexuality with others

2. Unveiling and debunking erroneous sexual myths and sex role
programming that interfere with autonomy and self-determina-
tion in sexual and nonsexual areas
3. Increasing knowledge of anatomy and physiology of female
sexuality
4. Learning more about and becoming more comfortable with one's
own body via self-exploration and directed masturbation
5. Permission-giving to increase sexual pleasure and playfulness;
information-giving to expand the sexual repertoire
6. Overcoming emotional blocks to sexual freedom (guilt, anxiety,
self-downing, anger) by challenging dysfunctional cognitions
7. Improving ability to assert oneself and to communicate sexual
preferences to one's partner
8. Developing plans for continuing sexual enhancement when the
group concludes
GROUP COMPOSITION AND SELECTION
We generally have found the optimal group size to be between six

and nine women. Although having two female co-therapists tends to
facilitate the group (and especially the construction and troubleshooting
of homework assignments), it is possible for one therapist who is highly
experienced in sex therapy and in conducting groups to lead a sexuality
group. Since the existence of a mastery model with perceived similarity
to group members appears to be a powerful factor in the groups' success
(Yalom, 1970), a female rather than a male therapist is seen as mandato-
ry. The all-female membership also reinforces the important idea that
women are the best authorities on their own sexuality.
Members in both the settings in which we operate (Walen in private
practice and a university setting; Wolfe in an outpatient clinic) generally
are self-referred or referred by colleagues. Although prescreening might
appear to be an absolute requirement of such groups, the fact is that in
several years of running the groups we have not encountered anyone
who was not able to participate in them. Those who have never partici-
pated in therapy groups, women who previously have had difficulties in
relating in mixed-gender groups, and even borderline clients have, in
the unusually supportive atmosphere of the theme-centered all-wom-
en's group, been able to open up fairly readily and to participate ac-
tively, abetted considerably by a "go around" format that allows each
woman to speak up at least two or three times during each session.
Although we run two kinds of groups, preorgasmic groups and
sexual enchancement groups, group composition is not rigidly restricted
to women with the same problem. Typically, there will be two or three
women in the preorgasmic group who define themselves as anorgasmic
either because they are having orgasms but not labeling them as such, or
are having orgasms in masturbation but not in intercourse. There also
will be two or three anorgasmic women in the sexual enhancement
groups. Not only have we not encountered any real difficulties in run-
ning mixed problem groups, but rather, we have experienced the mixing
as beneficial in that the members often derive encouragement from the
presence of coping models. Not uncommonly, for example, a pre-
orgasmic group member will encourage another by saying, "I used to be
where you are, and now I can do it. Here's something that worked for
me that maybe you might want to try." The already orgasmic member in
a preorgasmic group also illustrates the important lesson that orgasmic
ability is not a panacea-that having the ability to reach orgasm is no
guarantee of a problem-free sex life.
Ages of the group members generally range from early 20s through
the 60s. Although it is not mandatory to have each age group repre-
sented, it is generally helpful, where possible, to have an approximate
matching in order to avoid a feeling of being "the odd woman." Thus,
having two women in the 50 to 70 age group, or two women with
orthodox religious backgrounds, can enhance feelings of belonging and
support and provide better opportunities for vicarious learning. Ulti-
mately, however, the increasing awareness that there are more com-
monalities than differences among group members despite disparate
ages and backgrounds wins out over alienation. In our experience, hav-
ing at least two of any age group or background comes about naturally,
without any need for deliberate matching or additional recruitment.
PORTRAIT OF A TYPICAL GROUP
Looking at a woman in her 60s who has been married for 40 years,
another in her 30s who recently "came out" as a lesbian, another a
young woman who lives alone and has few friends, and a fourth a
bubbly, active person with two lovers, one might at first wonder what
they have in common and how they are going to identify with each
other. Common elements quickly become apparent as they introduce
themselves and discuss what they think they "should" be doing sexu-
ally. The following is a sample of the presenting problems taken from
some of our most recent sexual enhancement groups:
• "I should be having orgasms during intercourse-my boyfriend
says so. Otherwise, I'm denying him the pleasure of giving me an
orgasm."
• "I'm not sure if I have orgasms. I've heard that if you don't know
for sure, you haven't had one."
• "My husband's and my sex life has gotten dull and routine; I
know I should be enjoying sex with him and giving more to him."
• "I should be able to have sex without fantasy ... come fast-
er ... and have multiple orgasms."
• "I should be having vaginal orgasms."
• "I shouldn't take so long to come."
• "I should be able to express my needs-but I'm uncomfortable
because I think it's unfeminine and I'm afraid because if I tell him
now-after seven years of faking-he'll really be hurt."
• "I should want sex as much as my partner."
• "I only have orgasms with a vibrator, and think if I were really
healthy, I wouldn't need it and could come in 'sex.'"
• "I almost never feel turned on. I could take sex or leave it."
Most readily apparent-even in the most highly educated mem-
bers-is a great deal of sexual ignorance and inappropriate expectations.
The group member has feelings of shame and disgust toward her geni-
tals and basically dislikes her body. She is looking for the earth to move,
for stars exploding, for "coming" during intercourse. She does not trust
her own experience and does not think she is a "real" woman. She has
labeled herself as frigid, as has (frequently) her doctor if she is not
having orgasms in intercourse. She then thinks she is sick and incapable
of a good sex-love relationship. As a result, she has become more up-
tight, finding it harder than ever to let go and thus anticipating sex with
dread and experiencing arousal in terms of fright and cutting off. There
is at least one sexual practice (fantacizing, extramarital sex, oral stimula-
tion) that she has set up as the sine qua non of sexual health and for which
she condemns herself-for doing it, for not doing it, or for both. Her
facial expression changes from amused to moved to relieved as she
listens to each woman in turn provide a description of a set of problems
228 SusAN R. WALEN AND JANET L. WoLFE
overlapping remarkably with hers. She expresses genuine surprise as

she becomes aware that all of her well-put-together-looking, "normal"-
appearing groupmates are not the perfect, emotionally integrated crea-
tures she has imagined them to be in other settings-but in fact are very
much like her. She thus experiences tremendous relief within the first
hour of the group at discovering she is not the terrible and inadequate
sexual"freak" she always had imagined herself to be. She has received
and given to herself few positive messages about her sexuality and has
had few good models. The group will need to provide her with correct
information, to help her redefine her problems without the cognitive
castigation she usually imposes on herself, and to help her replace her
negative attitudes and feelings with more positive ones-all in a climate
of support and permission giving.
TREATMENT fORMAT AND ROLE OF THE LEADER(S)
Both the sexual enhancement groups and preorgasmic groups are

conducted on a time-limited, topic-centered basis. The range of time for
such groups as revealed in literature reports is 6-12 weeks, with the
group meeting one or two times each week for 1Vz to 2 hours. Although
our own groups are conducted for six weeks, meeting once a week for a
two-hour session, we strongly recommend that therapists who are not
highly experienced in working with groups and/or in the area of female
sexuality schedule a longer (8 to 12 week) group. With increasing experi-
ence, the therapist can conduct the workshop more efficiently. We have
found that with a 6-session format, the pressure of the limited time
encourages clients to come to the point, be more quickly self-disclosing,
and accomplish the work of therapy more efficiently and directly. The
greater efficiency of therapy when clients know it is to be time-limited
has been reported by Muench (1964) and Paul (1966). In our groups, the
bibliotherapy and behavioral homework assignments, as well as encour-
agements to keep sharing histories and discoveries with other women
friends outside the group, are seen as greatly helping to extend the
amount of therapy time the group members are getting beyond the 12
hours spent in the group.
The initial sessions of the groups that we conduct are more highly
structured than later sessions. In the first three meetings particularly,
the therapists contribute the majority of the agenda items in order to (a)
define each client's problems and socialize the client to the group and to
the cognitive focus of therapy; (b) provide experiences that will encour-
age group members to evaluate specific attitudes; and (c) teach clients
correct facts about sexuality. Throughout each session, however-more

so from the third session on (after the didactic groundwork has been
laid)-members are encouraged to present and work on their own indi-
vidual sexual problems.
During the course of the group the therapists utilize a number of
styles of presentation, including brief lectures, experiential exercises,
group discussion, individual problem focus, handouts, audio visual
aids, and assignment and review of homework. (Examples of these tech-
niques will be described later.) Varying the format in this way maintains
the interest of group members at a high level and thus maximizes learn-
ing and retention.
The role of the therapist is a difficult but challenging one, and it is
preferable that she be highly skilled and flexible. It is up to her to create
a climate of permission-giving, support, and encouragement while still
confronting resistances. She will be giving permission to push on and
try new things; or not to try so hard, to slow down and relax. She is to
serve as a participant-model, yet keep the group moving efficiently and,
maximizing opportunities for vicarious learning by picking up on group
process issues, tying together themes and people with similar problems.
She would do well to be highly skilled clinically in order to pick up
underlying issues and work with such areas as depression, couples
communication, and low self-esteem. To maximize her value as an edu-
cator, she needs to be highly informed about female sexuality, birth
control, and other female sexual health issues.
One of the leader's first tasks is to state clearly the theme that will be
reiterated again and again in the course of the group--sex is a natural
function that has been inhibited in them by psychosocial blocks; their
goal in the group will be to work together to help each other erase their old
inaccurate information and destructive attitudes and feelings in order to
reclaim and take control of their sexual identities and feelings. This is
facilitated from the start by the leaders helping the group members to
accurately label their problems. "Bad communication," for example,
really may mean a bad marriage. Very commonly, the therapist needs to
clarify and correct the woman's self-imposed diagnosis. Many women
come to the group defining themselves as frigid, meaning suffering from
primary anorgasmia. Typically, this label really means that the woman
does not experience orgasm during intercourse, but in fact is orgasmic in
other ways. Although some sex therapists would label this complaint as
situational anorgasmia, it is seen more correctly as normal sexual func-
tioning and clearly identified as such to the group·members, with the
explanation that 70% of women do not regularly orgasm during inter-
course (Hite, 1976). By this kind of reconceptualization, the leader is able
to correct misinformation, help the woman set a more realistic goal,

point out the role of "should-ing" and other cognitive components in
producing some of her distress, and begin to challenge during the first
session some of the traditional role scripting and cognitive self-castiga-
tion.
GENERAL THEMES
Before describing the session-by-session content of the groups, we

will outline a number of general themes that recur across sessions in
order to give the reader a sense of the flavor of the workshop.
Use of a Flooding Model. From the first moments of the first session,
the therapists actively and directively move to encourage frank and
open discussions of sexuality. Via modeling by the therapists, a flooding
rather than a cautious desensitization model is used. The cognitive mes-
sage transmitted by this model is that sex is neither taboo nor frighten-
ing and that the group members are not fragile infants who must ap-
proach a dangerous topic obliquely. Further desensitization is encour-
aged by having the women discuss a list of topics back and forth with at
least one outside woman friend and by reading as much material on the
sexuality reading list as they can.
Use of Informal and Lusty Language. An examination of the language
of sexuality proves very revealing. In English, we have a relative paucity
of terms for many aspects of sexual functioning. For example, there are
no direct synonyms for clitoris, the female sex organ. This fact suggests
the cultural devaluation of the woman's sexuality and may, in part,
account for the difficulty many women experience in talking about sex.
Similarly, the majority of colloquialisms used for masturbation are de-
scriptive only of male masturbation (e.g., "beat the meat" or "pull the
pud"). In addition, many of the terms for female masturbation seem to
have been coined by men (e.g., "finger fuck") and are not accurate
representations of how women masturbate.
An additional problem of our language of female sexuality is that
terms are used loosely and with inaccurate referents. When asked for
synonyms for the word vagina, for example, the words most frequently
cited by students were "cunt" and "pussy" (Walen, 1978). Yet these
words were meant to convey the entire genital area, not merely the
vaginal canal. As Hite (1976) reports, even when women are describing
an activity they have positive feelings about (e.g., cunnilingus), they
tend to describe it in "spare, tight, unenthusiastic and secretive Ian-
guage." It is pointed out to group members that if a hallmark of good

partner sex is good communication-the ability to express sexual prefer-
ences clearly, directly, and comfortably-then developing and practic-
ing a new sexual vocabulary is very important. When people think about
their own genitalia and the sex acts in which they engage, they do not
think in technical or medical terminology. We believe strongly that
therepists should be prepared to accept this fact and freely model such
behavior. When therapists comfortably use the informal and lusty lan-
guage of sex, they may illustrate meaningfully a different attitude to-
ward sexuality-the playful, demystified attitude we wish to project. In
addition, since many women have only passive sexual vocabularies, the
therapists' modeling may help clients move these terms from passive to
active vocabulary. The most common words to describe male and female
genitalia are cock and cunt, and these are the words we use most fre-
quently in the groups.
Focus on Sex-Role Socialization Messages. An important theme in our
workshops is consciousness raising about the unequal position of wom-
en in our society. We stress that it is unlikely that women will obtain
sexual equality if they are not working toward human equality. For
example, many women grow up with the cultural notion that most of
their worth as people depends on their "feminine allure." They are
encouraged to use their sexuality indirectly to get what they want from
men, but at the same time are not supposed to take an active role or to
enjoy sex. Whenever it is relevant, we point out the importance of such
socialization messages that is continuing to interfere with the women's
sexual enjoyment and general self-actualization, and encourage group
members (especially those with no previous exposure to feminist writ-
ings) to read some of the recommended "consciousness-raising" litera-
ture on the effects of traditional female sex-role socialization.
Focus on Changing Cognitions. Group members are consistently aided
in identifying and challenging the dysfunctional thoughts that result in
emotional turmoil and that block sexual functioning. They are helped to
examine their perceptions and evaluations of their own sexual function-
ing, their partner's behavior, and environmental events. The cognitive
focus is taught by mini-lectures on the techniques of cognitive and ra-
tional-emotive therapy, and its techniques are demonstrated on indi-
vidual problems brought up by the group members. A New Guide to
Rational Living (Ellis & Harper, 1975) is recommended to all group mem-
bers for further elaboration of cognitive self-help procedures.
Focus on Changing Behavior. One way to feel better, to change atti-
tudes, or to reinforce attitude change is to behave differently. This mes-
sage is presented repeatedly at all sessions. Group members are encour-

aged to practice new behaviors and challenge themselves with new
behavioral risks both within the group sessions (e.g., asking for clarifica-
tion or help with a problem) and in homework assignments. These new
behaviors may be sexual or nonsexual in nature.
Focus on Self-Acceptance. Whether or not group members want to
change their attitudes or learn new skills, we believe that an important
first step is acceptance of the now. By this term we mean acceptance of
oneself, acceptance of one's partner, and acceptance of reality. Very
commonly, group members may be blaming themselves heavily or
blaming their partners for not doing what they want them to do. The
resultant emotions, whether anger or depression, are incompatible with
good sexual functioning. We therefore encourage the women to focus
first on feeling better about the sex they are doing, rather than merely on
doing better sex. Once this nondemanding philosophy is accepted, they
can move forward far more efficiently.
Focus on Hedonism. Many of the cognitive and behavioral assign-
ments used in the group are designed to inculcate and implement a
generalized hedonic philosophy. Assignments are not merely sexual,
therefore, but are broadly self-pleasuring, designed especially to rein-
force the idea that "I have a right to have pleasure." Until a woman
adopts this broader notion, she often will have difficulty allowing her-
self pleasure in sexuality.
The impact of sex-role socialization is seen clearly in this area, and is
often particularly strong in women with strict religious upbringing or
those who are deeply embedded in their roles as wives and mothers.
Such women define their role as that of taking care of other people, and
often have grossly neglected the habit of doing nice things for them-
selves. Assignments such as taking a leisurely bubble bath or buying
flowers for oneself may serve to combat guilt or thoughts of "selfish-
ness," and may encourage a more general acceptance of hedonic self-
pleasuring.
Use of Humor. Humor is another way in which the hedonic philoso-
phy is asserted. We attempt to keep a light, playful attitude, replete with
puns and witticisms, whenever it seems appropriate. Humor is another
way of teaching women that it is appropriate and healthy to have fun.
Humor also is an important desensitizer. Not only is it all right to have
fun, but to make fun of things. Obviously, the group members are never
the butt of a joke, although their cognitive distortions may be. It is our
experience that an efficient way to explode myths and attack taboos is to
help clients realize the absurdity of some of these notions.
Focus on Women's Health Issues. Because of the large amount of igno-

rance regarding their bodies and what happens to them, time always is
taken in the groups to inform women about such issues as the relative
risks of the different birth control methods, how to detect some of the
common "female problems" (such as vaginal infections), and proper
ways to go about treating them. Frequently this involves some further
demystification of the role of "doctors as sex experts" as the women
become aware of the inadequate treatment almost all of them have re-
ceived at one time or another, and learn new ways of dealing more
assertively with physicians in the future so as to receive better care. Our
Bodies, Ourselves (Boston Women's Health Collective, 1976) is highly
recommended as a handbook for helping the women become more edu-
cated about and responsible for the healthy functioning of their bodies.
Leaders as Participants. The co-therapists in our groups function very
much as participant models rather than as distant or aloof experts. As
leaders, we are very self-disclosing about our own sexuality. In fact, on
every exercise in which group members are asked to self-disclose inti-
mately (e.g., sharing details of how we masturbate), the group leaders
participate and demonstrate free disclosure and a coping (or successfully
"coped") model. As Yalom (1970) points out, a therapist who is self-
disclosing; who models open, direct, and uninhibited communication;
and who has had similar problems, but overcome them, greatly in-
creases the therapeutic power of the group.
Participants as Leaders. One of the most significant themes of the
group is that other women are the best source of information about
female sexuality-not male PhD's, doctors, or other "sex experts." An
important cognitive message given to the group is that there is no "right
way" to have sex, but that it is up to each woman to define her sexuality
and sexual preferences for herself. Both within and outside the group,
members are encouraged to find out how other women think and feel
about sexuality and how they go about it. They learn to acquire the
capacity to abstract personally relevant information and helpful hints
even when the spotlight of attention is not directly focused on them.
They give each other substantial support and permission to be sexual.
They share with each other by providing in-group practice in taking
risks, communicating feelings, and sharing their own specific sexual
practices. This in-session sharing helps enormously in building better
facility in talking to and dealing with their partners outside the group.
The Hite Report (1976), which is a compilation of the questionnaire re-
sponses of over 3,000 women, is recommended reading because it
serves to amplify the theme of women as experts. It provides new in-
sights and techniques while increasing their awareness that they are not
alone but part of an ever growing "army" of women struggling together
for sexual self-determination.
SESSION-BY-SESSION FORMAT: A SAMPLE MODEL
The following format is used in both types of groups we conduct,

the preorgasmic and the sexual enhancement groups. The main dif-
ference between the two types is that the amount of time spent on
troubleshooting masturbatory practice sessions understandably is short-
ened in the enhancement groups, which generally have only two or
three anorgasmic women (as opposed to the preorgasmic groups, in
which they represent the majority); and the intensive individual prob-
lem solving tends to begin in the second or third session in the enhance-
ment groups, with a correspondingly heavier focus on partner prob-
lems.
Session 1
Once the group is convened, the therapist opens the first meeting
by congratulating the women for attending and challenging their first
sexual stereotype-sex should be naturally perfect. We ask the members
to give their first names, and set forth the group rule of absolute confi-
dentiality, explaining its importance in allowing the women to be as free
as possible to express themselves. Each participant then is asked to tell
the group something about herself, incorporating the following informa-
tion into her responses: What are you worried or concerned about sexu-
ally? Are you orgasmic? Are you currently in a relationship or not, and
what are your feelings about this? How does your partner feel about
your being here? Each woman typically speaks for 5 to 10 minutes. If the
target questions are not answered or if the client digresses or speaks for
a prolonged time, the therapists guide her back to task.
The next phase of the meeting is devoted to illustrating some of the
detrimental sexual stereotypes that women encounter. An exercise that
we find especially useful is to ask the women to call out words or
phrases that come to mind for each of the following categories: (1) wom-
en who are sexually active; (2) women who prefer not to be sexually
active; (3) men who are sexually active; (4) men who prefer not to be
sexually active; and (5) women who are very self-determined about their
sexuality. The responses are written in columns on a blackboard or
tagboard, and the women are asked what trends they notice in the
responses. What clearly emerges from this "nasty name" exercise is that
men who are sexually active are prized (e.g., called swingers or macho),
while women who are sexually active are condemned (e.g., referred to
as whores, promiscuous, or loose). Women who are inactive are castigated
(e.g., dyke, frigid), while men who are inactive are derogated by associat-
ing them with females (e.g., momma's boy, fairy). Finally, women who
are self-determined are seen as pushy or aggressive and destructive of
male sexual prowess (e.g., ball buster or castrating woman). This exer-
cise-a powerful consciousness raiser (Kellogg, 1973)- is followed by a
discussion of the lack of adequate models for healthy sexuality in wom-
en, including a review of some statistics on the sexual oppression of
women. The goal in this section of the workshop is to provide women
with valid understanding of their problems in dealing with their sexu-
ality. The message is that they are not deficient, but have been raised in a
culture where different standards exist for men and for women and
where the missionary position in sex serves as a dramatic metaphor for
women's position in this society; lying flat on her back, on the bottom,
getting fucked (over). Some brief data citing on some of the facts of
women's oppression is done, with active contributions from the group
members, at least 50% of whom generally have been raped or sexually
molested at some time, who have worked as hard and long as men but
for less money (the median income of full-time working females is ap-
proximately $5,000 a year less than it is for males); who have been
patronized and been told "not to bother your pretty little head" about
financial and mechanical things. Slowly, the women come to see that
although they certainly have collaborated in perpetuating their helpless-
ness and dependency, the facts of reduced power and respect in a male-
dominated society do not make things easier and that they will need to
work long and hard at countering both internal and external forces in
order to claim their fullness, strength, and autonomy.
During the second hour of the first session, basic education about
the anatomy and physiology of sex is provided. Because there are so few
adequate illustrations of female genitalia, we have had local artists pre-
pare very large, softly colored drawings of female external genitals in
which the clitoris and clitoral head and shaft are depicted clearly. During
the anatomy lesson, the therapists continue to stress the role of the
clitoris by referring to it as "the clitoris, your sex organ." The message
passed down in the culture and often reinforced by the male partner is
that the vagina is "where it's at." In sex education classes, girls still for
the most part are taught that they have two ovaries, a uterus, and a
vagina. Group members frequently report that they never even mastur-
bated or heard of the clitoris until they were in their 20s, 30s, or even 50s
or 60s. (Boys generally are taught about their sex organs and about
masturbation in sex education classes.) An image that many group
members report as powerful and corrective is viewing intercourse as
male masturbation (i.e., rubbing of his sex organ against the walls of her
reproductive organ) thus making it a small wonder that the woman
often finds this stimulation insufficient to induce orgasm. It is stressed
again and again that orgasm is a learned response and that failure to
experience it is not a sign of neurosis but of faulty or inadequate early
learning, and that in a culture in which millions of men and women
barely recognize women or their organs, it is no surprise that women
have not learned how to reach orgasm. In the end, failure to achieve that
shining, male-established goal of female orgasm in intercourse is, as
Hite (1976) points out, not a deficiency but a normal response to insuffi-
cient stimulation.
We review the physiology of the sexual response cycle, drawing
principally on the work of Masters and Johnson (1970) and Kaplan
(1974). In this segment we particularly stress the fact that vaginal lubri-
cation is a very early sign of sexual arousal and does not mean that the
woman is near her orgasmic threshold. This bit of information may be
corrective for her partner who, in many cases, tests her readiness for
intercourse by inserting his finger into her vagina to see if it is wet. In
this as in all phases of the group we avoid the use of technical language.
Thus, rather than clinically describing the "formation of the orgasmic
platform at the lower third of the vaginal entroitus," we simply describe
the arousal and plateau stages in terms of "blood flowing to the cunt
and swelling the tissues, much in the same way as blood flows to the
man's cock and causes it to swell."
If time allows, we explore the group members' attitudes and feel-
ings about their bodies, following the "go-around" format that allows all
the women to talk at least two or three times, from the first session on.
They may be asked to imagine themselves looking at themselves in the
mirror nude, and to share with the group whether their feelings were
positive or negative; to what extent their feelings about their bodies
influence how they feel about themselves as a sexual person; and to
what extent they feel they are valued (or devalued) by others for their
bodies. They are encouraged to work on accepting themselves and on
giving themselves the right to be sexual persons, whether or not they
have perfect bodies. We conclude the first session by encouraging the
women to "ask any dumb questions you've ever had about sex and were
afraid to ask . . . you can even ask an intelligent question!" We are
thereby accomplishing several tasks at once: (1) picking up on loose
SEXUAL ENHAN CEMENT GROUPS FOR WOMEN 237
ends, (2) allowing the group members to take responsibility for their
own sex education, and thus their own sexuality, (3) providing practice
in verbally communicating about their sexual wants, and (4) reinforcing
the message that it is all right to sound " dumb," to make mistakes, to
show you are imperfect. At the end of the question-and-answer period,
we hand out the first homework assignment (below).
HOMEWORKI
Session 1
1. Exploring your attitudes and development as a sexual being
Sit down and discuss with a female friend the following experiences
you had while growing up:
(a) What were your parents' (or parent-substitutes') attitudes toward
sex? Your mother's? Your father's? How were they communi-
cated to you?
(b) What was the attitude of your peers toward sex as you were
growing up?
(c) When and how did you learn about menstruation? What was the
attitude of the person who told you? Were you frequently very
uncomfortable-for example, have cramps? Did you ever feel em-
barrassed by an incident involving menstruation?
(d) When and how did you learn about masturbation? What is the
earliest self-pleasuring or masturbation experience you can re-
member?
(e) When and how did you first learn what sex really was? Were you
shocked?
(f) What were the circumstances of your first real sexual experience
and what was it like for you?
(g) Did you ever have "crushes" on a girlfriend or any roman-
tic/physical feelings for another girl or woman?
(h) When did you first hear the name of your sex organ, the clitoris?
(z) Do you remember any sexual traumas such as child-adult sexual
contact, rape, or other frightenig sexual experiences?
Spend 5 to 10 minutes with your friend on each question.
1Adapted from Lonnie G. Harbach's For Yourself (New York: Doubleday, 1975).
2. Explore your genitals

Get yourself relaxed and comfortable. Bathe or shower if you wish.
Spend 20 minutes to half an hour, in a quiet room where you will not
be disturbed, examining your genitals with a hand mirror. Get to
know them. Identify all parts of them and touch each with your
fingers, using the attached drawing as a guide. Notice the colors and
textures. See if you can determine any differences in sensitivities
between the different areas. Place your fingers inside your vagina to
feel the pubococcygeal muscle and to see if some areas are more
sensitive to touch than others. Separate the labia and look at all the
details. Notice the three parts of the clitoris: the shaft (the tube-like
structure just below the pubic hair-you can find it by rolling your
fingers from side to side over it); the glans (the little pea-like struc-
ture); and the foreskin (the movable hood overhanging the glans).
Try moving the hood of the clitoris back and forth over the glans.
Repeat this exercise on subsequent days, until you feel comfortable.
3. Exercise your pubococcygeal muscle (optional)
This is the large muscle that surrounds the vaginal opening, and
covers the whole pelvic floor. To locate it, urinate with your legs
slightly apart; the muscle you squeeze to stop the flow is the pubo-
coccygeal (or PC) muscle. Lie down and put your finger in the open-
ing of your vagina and contract the PC muscle; feel the contraction
around your fingers. Practice contracting this muscle at least three
different times over the next we k, spending about two to three
minutes each time. Do each contraction to a count of approximately 6
seconds, until you have done it about 6 to 10 times. Flexing this
muscle can be another way to help you tune into your genital sensa-
tions.
4. Beginning masturbation
Pick a time when you can relax, unwind, and be sure of not being
interrupted. Lie comfortably on your bed, without clothes. Using a
lubricant such as mas age oil, baby oil, or your own natural aliva or
vaginal juices, begin to explore your vaginal area, slowly and gently.
Experiment with different types of strokes and pressures: light, feath-
ery touches, harder rubbing, in-between strokes. Try massaging your
clitoral area with your fingertips by making gentle, firm, circular
motions. Find out what feels best for you: Direct stimulation of the
glans? Massaging the areas directly surrounding the clitoris above,
below, or to the sides? You may try massaging the clitoris between
your forefinger and middle finger or massaging the who) area.
Feel what there is to feel. Don't hold back, don't measur your
sensations. At first you may not feel very many sensations; but con-
tinue, and take notice of even slight feelings. Focus on what is there,
FIGURE I. Drawing of female genital anatomy used as a handout in women's sexual

enhancement groups. (From For Yourself: The Fulfillment of Female Sexuality by Lonnie
Barbach. Copyright 1975 by Lonnie Garfield Barbach . Reprinted by permission of Double-
day & Company, Inc.)
240 SUSAN R. WALEN AND }ANET L. WOLFE
not on what is not there. You are looking to get to know your body
and how you feel and react, not for instant orgasm. Use mental
aphrodisiacs if you wish: fantasize or read an erotic book or maga-
zine. Repeat this exercise at least two or three times (for at least 15
minutes each time) over the next week. Move slowly; do not push
yourself. There is no need to discover the whole range of feelings in
one day or even one week. Little by little, you will learn to feel safe
with your sensations and with your sexual responses. Do not shoot
for orgasm. Slowly, quietly allow sexual tensions to build up, ebb,
build up, ebb.
We begin the second session by asking the group members for their
reactions to the first session. If they experienced any distress we help
them to challenge their automatic thoughts. Typically, however, there is
a warm expression of relief and encouragement that is strengthened as
the group discusses the first meeting. We then review their homework
assignments, thereby learning more about each participant and helping
the women who had difficulty in doing the homework to identify their
emotional blocks and other resistances and to develop specific plans for
working against them. Not uncommonly, several members will plead
that they were "too busy," their kids were underfoot, or they were "too
tired" to do the exercises. Low frustration tolerance (avoiding the anx-
iety accompanying difficult and uncomfortable situations) and lack of
belief in their right to take time and space for themselves are pinpointed
by the leaders as being contributory to these resistances, and appropri-
ate cognitive and behavioral homework assignments are suggested,
along with practical advice (such as borrowing a friend's empty apart-
ment).
The focus of Session 2 is on masturbation-learning to be one's own
best sex partner-and on increasing comfort with their bodies. Group
members are asked for their feelings about touching their bodies and
about being their own sex partners. A great deal of the ensuing discus-
sion entails cognitive challenges to feelings of guilt, anxiety, or revul-
sion. The claim made by members that sex is so much better with a
partner than alone is met with the explanation that 95% of women who
masturbate have orgasms most of the time-a far higher percentage
than occurs in partner sex and thus a more reliable way to reach orgasm.
Other advantages given are the freedom from being observed and its
frequent attendent anxieties; the fact that one does not need to have an
SEXUAL ENHANCEMENT GRouPs FOR WoMEN 241
available partner to have sexual pleasure and that women tend to have
difficulty in seeing themselves as having sexual feelings and desires
other than those resulting from male initiation. Finally, it is explained
that if one can learn comfortably and reliably to reach orgasm with
oneself, one is likely to enjoy it all the more with a cooperating partner.
During the final segment of this session in the sexual enhancement
groups, each woman describes in detail the various ways she mastur-
bates. (In the preorgasmic groups, this discussion would normally not
take place until session three, as group members tend to have had
relatively little masturbatory practice, and thus might feel inadequate
about their descriptions.) All members are encouraged to ask each other
as many direct questions as they wish. For most women, this exercise
may be the first time they ever have spoken to anyone about the subject
of masturbation and is almost always the first time they have verbalized
their masturbatory procedures. Our members often decide to give them-
selves the assignment of trying out someone else's method just for fun,
thereby providing the originator with perhaps her first exhilarating ex-
perience in being a teacher in sexuality. This exercise allows us to identify
any potentially troublesome styles of masturbation. For example, one
woman had trained herself since early childhood to reach orgasm only
while in a tightly curled position, one which clearly would make good
partner sex quite difficult. Additionally, we can provide cognitive cor-
rections about masturbation (e.g., ''I'm probably the only person who
masturbates-or doesn't masturbate" or ''I'm doing it the wrong way").
Finally, we can help the group members to identify and correct their
cognitive blocks to orgasm.
The women in the sexual enhancement and preorgasmic groups are
asked to share with the group a description of "the sexiest experience
you ever had with yourself." As in all such disclosure exercises, the
leaders share one of their own experiences. The women then are asked
"what prevents you from doing more of that for yourself?" Again, guilt
reduction is the typical therapeutic focus. Since many of the women's
sexiest experiences tend to be their more unusual ones (e.g., masturbat-
ing on a secluded beach or with a cucumber), the group members (talk-
ing for perhaps the first time about their "dark secrets") receive practice
in seeing that the "freaky" things they have done sexually were in fact
not so freaky or shameful after all. This tends to pave the way for
increasing levels of self-disclosure. At the next session, for example, a
woman may share the information that she is having her first affair and
is almost sick with anxiety and guilt about it. The group members'
reaction almost invariably is support and empathy and not the condem-
nation and rejection she had imagined would occur.
At the end of the session, the second homework assignment is

given out (see below), and the women are encouraged to bring to the
next session any sex "toys," sex books, magazines, or vibrators they
may have.
HOMEWORK2
Session 2
Welcome to Masturbation Week!
Remember-it's important to make an agreement with yourself that
if improving your sex life is important, you'll have to set aside enough
time for you to work on it. A minimum of four separate 20-minute to 45-
minute sessions this week is recommended.
Pick a time of day when you're relaxed, and feeling reasonably good
about yourself. Find a place (your bed, in front of the fireplace, in the
bathtub, wherever) that's quiet, comfortable, and where you won't be
interrupted. (Turn off the phone!) Create a sensuous atmosphere; turn
down the lights, turn on background music, if you wish. Feel free to do
whatever may help you to get in a more sensuous mood and arouse
your sexual fantasies. This may include looking at sexy pictures in a
magazine, reading an erotic book, or thinking up sexy experience or
fantasies.
Remember some of the places that felt particularly good when you
touched them last week. Remember, too, that masturbation is a natural
body function, and is GOOD for you; give yourself permission, out
loud, if you wish, to enjoy it.
ow, all you need is a little perseverence. You might not get excited
for quite a while, or might not have any orgasm. These kinds of re-
sponses take practice. DO 'T WORRY.
Using some oil (or secretions) for lubrication, find an enjoyable
place to stroke. When you've found one, keep rubbing, alternating the
pressure and the rate. Try stroking up and down; try stroking sideways,
in circles, back and forth. Try rubbing as though you were massaging
yourself to reach the parts below the skin. Don't worry if you tem-
porarily lose the pleasurable feeling. If a place becomes tender, or numb,
witch to a new place. Stop when you want, start when you want. Do
what feels O.K. for you. Try whatever positions, movements, or stim-
ulation you want (with pillow, objects, whatever). Use one hand or
2for additional reference material see Barbach (1975); Heimann, LoPiccolo, & LoPiccolo
(1976); Dodson (1974); SAR Guide (1975).
both. Touch yourself elsewhere on your body-your breasts, inside of

legs and arms, face-experimen t. Find what feels good. Make as much
or as little noise as you want. And try to remember that there is no
"right" or "best" way to masturbate- there's your way. And finding
your way takes trying out lots and lot of different things. YOU HAVE
THE RIGHT TO PLEASURE . . . but ever:t pleasure takes practice.
Why Masturbate?
Masturbation or self-stimulation for sexual pleasure is liberating for

men and women. It's a most natural function--child ren do it-develop-
ing guilt mainly when others start telling them it's wrong. Looking at
and touching your genitals helps you gain greater comfort and accep-
tance of your sexuality and your body. And it helps you become more
attuned to what feels good and better able to enjoy your exual re-
spon es-both with your most reliable sex partner (your elf!) and with
others. It is the best way to learn about your own se ual responses so
that you can communicate them more clearly and effectively to your
partner.
Masturbation can, if you so choose, be your primary xual outlet.
lt' a great way to relieve exual and other tensions (and a good nightcap
to help you sleep!) With a partner, it can take the pressure off your
partner (and you) to perform. It is one of many ways to share se ual
experiences and techniques and to develop greater sexual honesty with
your partner. It can b a tremendou turn-on to ee omeone you car
about give th mselve plea ure . Finally, people who feel good abou t
pleasuring themselves and who take re pon ibility for their e ual re-
ponses are less likely to have exual problem .
Session 3
Goals in this session are to continue to troubleshoot the factors
interfering with orgasmic response and body comfort and to help extend
the members' awareness of new things they might try to expand their
sexual repertoires. The session begins with the women sharing their
sexual paraphernalia with each other and leaders encouraging swapping
of books or magazines. The leaders also bring in a variety of vibrators for
demonstration and discuss their various advantages and disadvantages .
Those requesting it are given information on places where they may
obtain such sex toys and materials. A dam seems to have broken during
this "show and tell" section: many of the women previously had consid-
ered such devices but never had tried them, out of shame and anxiety.
Again, the message is: "Sexual experimentatio n is healthy and natural.
I'm not a pervert or an inadequate person if I go into a department store

to buy a vibrator." We continue with a review of the homework assign-
ments and continue to stress the need for taking time for ourselves for
our pleasure. We also initiate a discussion of sexual fantasies, stressing
the positive value of fantasies, discriminating between fantasy and real-
ity (e.g., one may enjoy a particular fantasy-such as having sex with
the entire church choir-without having to worry about acting it out),
and encouraging women to develop and expand their fantasy life. Books
that women tend to find erotic, such as Friday's My Secret Garden (1975),
are recommended.
The focus of the latter part of this session is on clarifying the role of
cognitive therapy techniques in dispelling emotional blocks to sexuality.
The theory of cognitive therapy is described, and by working with indi-
vidual members of the group, the members learn directly and vicarious-
ly how to apply these methods to their problems of anger, anxiety, guilt,
depression, and especially, low frustration tolerance. One way we have
found particularly effective in helping group members identify their
main dysfunctional cognitions is to give them a handout with Ellis's
(1975) "Twelve Irrational Ideas that Cause Disturbance" in the left col-
umn and his corresponding rational countermessages in the right col-
umn. Each women is asked to identify to the group two of these self-
messages she plans to work on over the next week (via overt and covert
rehearsal) and is encouraged by the leaders to work on this new pro-
gramming "every hour on the hour," if possible.
The session concludes with individualized assignments to the mem-
bers involving self-nurturance and/or the taking of new behavioral risks.
For example, one woman assigned herself the task of telling her partner
that she wanted him to "go down on her." Another assigned herself the
task of getting a lock put on the inside of her bedroom door and inform-
ing her children that she wanted them to knock if they wanted to enter.
If there is time at the end of the group we may show parts of the series of
films Becoming Orgasmic by LoPiccolo and Heiman (1976). This film series
provides a useful coping model of a woman learning to be orgasmic and,
in the later segments, communicating her new skills to her partner.
Session 4
We begin this session by asking for "reports from the field." By
such an open-ended structure we allow more opportunity for group
members to use this session to bring out their individual problems for
therapeutic intervention. The majority of this session is spent in this
individual focus.
The main agenda item we introduce in the latter part of the second
hour is bridging the gap between what the women are learning about
their own sexuality and their partner(s). We define assertive behavior
and discuss the factors responsible for women's especially heavy prob-
lems in this area, focussing on sex-role socialization messages (e.g., "Be
sweet," "Don't rock the boat," "Take care of others," "Don't express
anger-it's unfeminine"). Part of taking charge of one's sexuality, it is
pointed out, involves challenging the old notion that it is up to a man to
satisfy a woman, that he will do so if he really loves her, without any
coaching, and that if she lets him know what she wants, she will "hurt"
him or be "castrating." Particular attention is paid to handling sexual
initiations and refusals and asking your partner for what you want.
Other areas raised by participants include dealing with a partner's re-
sistance to doing the kind of stimulation she wants or to having a vibra-
tor join them in bed; expressing negative feelings about her partner's
behavior in nonsexual areas; asking for more snuggling and cuddling;
and expressing positive feelings. A belief system that supports assertive
behavior is developed by the group, typically including the following:
(1) I am in control of the way I feel about my partner; (2) I am able to
make appropriate choices about how I relate to my partner; (3) I am a
strong and centered person, with the right to be treated with respect, to
have my desires considered, and to have my time taken seriously. Role
playing and feedback are used to help members get practice in commu-
nicating their thoughts and feelings in more appropriate ways, along
with modeling by the therapist or other group members, where appro-
priate.
Homework assignments are, by this session, usually given by the
women to themselves, with other group members supplementing them
and the leader picking up any loose ends or making additional sug-
gestions. This process underscores the group members' ability to create
their own solutions and fades out some more of their reliance on the
"authority figures." As an additional assignment, each member is asked
to think about the following questions: What do you want done to you?
What, if anything, do you want to do for your partner? Members are
asked especially to think of things that they never have tried before and
then to try at least one of them out during the week, thus incorporating
risk taking and assertiveness assignments into one.
Session 5
This session basically is unstructured by the therapists, allowing the
participants maximum opportunity to bring up their own agenda items.
Two topics generally emerge: dealing with (sex-interfering) anger at

one's partner for inconsiderate sexual or nonsexual behavior, and han-
dling difficulties in dealing with their partner's focus on goal-directed
sex (orgasm) rather than on intimacy, kissing, cuddling, sensuous strok-
ing, and the other activities they love. (Almost invariably, the group
sighs in unison when asked to get in touch with their feelings about
snuggling via an experiential exercise often introduced at this point.)
Anger issues are dealt with by a mini-lecture on the cognitive bases of
anger and by role playing and feedback. The problem of getting off a
"fuck focus" is dealt with by introducing how to do mutual "informa-
tion massages" and other sensate focus procedures. A handout with
instructions for some of these is given out to group members with a
caution not to go ahead with them if there is a significant relationship
problem or a partner who flatly refuses to participate in nonorgasmic
sex. In these situations, members are encouraged to go for couples
counseling.
Another focus provided by the therapists during the second hour is
preparation for the future, since the sixth session is usually scheduled
after an interlude of three to six weeks. Each member is asked to re-
spond to the following questions: How will you try to make sure that
you don't backslide? What will you plan to do for yourself in the next
month? What are your future goals for yourself? For your sexuality?
Additional risk-taking exercises and other supplementary assignments
also may be suggested by the other group members and the leaders. The
follow-up meeting is then scheduled, and the women are asked if they
wish to arrange to bring refreshments to it.
Session 6
The follow-up session usually is conducted in a very relaxed atmo-
sphere, typically with wine and refreshments provided by the leaders
and group members. The first agenda item is a review of each woman's
progress, checking for backsliding, stability, or new progress. Not un-
commonly, significant changes have occurred in the women's lives
(e.g., loss of a partner, change of job, etc.), and the impact of these
changes on sexuality is assessed. Often, therefore, the follow-up meet-
ing revolves around general life-change stresses and developing coping
strategies for handling them. In such cases, sex may be the frosting on
the cake. If there are emotional problems relating to such issues as
health, finances, or relationship crises, it generally is best to deal with
these first.
Another common focus of the follow-up meeting is to provide what

amounts to an advanced course in sexuality. Since the group's incep-
tion, many of the women will have taken new risks, tried new sexual
experiences, and read a great deal on the topic of sexuality-all of which
may open new areas for questions. We therefore ask group members at
some point in the meeting to pick some item, hopefully one that always
has been particularly difficult or embarrassing for them to discuss, and
to throw it out to the other group members for their response. For
example, in a recent follow-up group, questions such as the following
were raised: "Do you swallow your partner's cum when you go down
on him," "How do you protect yourself against VD if you know your
lover is sleeping with other women?" and "Is anal sex bad for you?"
During this final meeting it is common for the members--by now
closely involved in each others' lives--to express sadness that the group
is ending. The therapists may suggest that group members exchange
names and phone numbers, and that if they wish they may arrange for
periodic reunions, with or without the leader. This suggestion typically
leads to the group electing an informal secretary to take charge of ar-
ranging such reunions and clearing them with the leaders' schedules. If
there is time, we may conclude the session with a final film. One that
has been used with great success is Going Down to Bimini, available from
Multi-Media Resources.
ILLUSTRATIVE CASES
The following four cases--representing a variety of ages, back-

grounds, and presenting problems--are offered to provide a clearer pic-
ture of typical problems and cognitive/behavioral homeworks given
during a six-session group.
CASE STUDY 1: pATRICIA
Session I
Key Issues
A 31-year-old teacher whose parents had told her she was so ugly she never
would find anyone who could be attracted to her. Shy and un-self-confident,
sees self as "asexual." Never orgasmed during masturbation, but thinks she
once came with a partner. Little dating experience; no sexual contact in last two
years.
Cognitive Assignments
Challenge belief that "l:>ecause my parents think I'm a sexual washout, it
must be true." Give self message that "I have a right to, and capacity for, sexual
pleasure."
Behavioral Assignments
Session 1 homework (see pp. 237-240).
Session II
Key Issues
When discussing sexual history with two friends, found they did not know
common sexual facts, and felt relief at discovery she was not as backward as she
had thought. Felt freer to spend more time touching body than ever before
(completed three sessions of self-exploration). Still feeling doubtful about
orgasmic potential.
Reinforce beliefs that "I have a right to proceed at my own sexual pace" and
"just because I'm having difficulty coming, doesn't mean I never will." Read My
Secret Garden to help erotic focus.
Session 2 masturbation homework (see 242-243).
Session III
Key Issues
Reported "I still think I'm the only one who's not going to make it." Felt
she was getting close to orgasm, but was scared she would "lose control, or lose
consciousness--maybe even die."
Challenge beliefs that "I can't control my feelings/behavior" and "if some-
thing is fearsome, I must remain terribly upset about it."
Call another group member (who volunteered the suggestion) before be-
ginning each masturbating session and ask her to phone 1V2 hours later to check
and see if she (Pat) is O.K.
Session IV
Key Issues
Felt much more relaxed during masturbation, so did not feel need to call
group member "but was very reassured to know I had someone who could help
if I was in trouble." Felt very close to orgasm; got scared but pushed self for
another minute or two; then gave self permission to stop.
Anti-awfulize about not coming (or possibly coming!); plug in erotic imag-
ery to distract self from "spectatoring." Read Hite Report for additional mastur-
bation ideas/ experiences.
Focus on erotic sensations; try two new masturbation techniques suggested
by group or Hite respondents.
Session V
Key Issues
When feeling discouraged, decided to cheer self on with "Yeah, cunt, do
your stunt!" (group applauds). Felt legs tensing, followed by relaxed, mellow
feeling, but not sure it was an orgasm. (Group members assured her it almost
certainly was, and probably would get more and more clearly punctuated, the
more she "practiced.") Brought up fears of meeting men and being rejected by
them.
Remind self to focus on good sensations and anti-awfulize about its "taking
so long." Challenge idea that it is awful to be rejected, to be uncomfortable in
social situations.
Continue to masturbate; try using vibrator in a "teasing" fashion; continue
to use favorite fantasies. Go to one social event (of several suggested by group)
and approach and converse with two new males.
Session VI
Key Issues
More clearly articulated orgasms; feels ready to approach partner sex. Role-
played discussing with potential partner her sexual wants (also saying "no" if
she didn't feel ready). Says through group she has "gone from being asexual to
actually being horny-I think about sex at work and can't wait to get home and
try it!"
(To prepare her for nonsexual and sexual risk-taking): Reinforce belief that
it's O.K. to be imperfect, and that rejection is neither awful nor proof of her
inadequacy. Read Intelligent Woman's Guide to Dating and Mating.
Increase assertive behavior, including giving and accepting compliments,
asking for favors, making more spontaneous comments at work and in social
situations.
CASE STUDY 2: AUDREY

Session I
Key Issues
A 44-year-old lawyer, married 12 years. Had orgasm once, in 20s, while
necking, through manual stimulation. Little sexual enjoyment with husband,
who criticizes her for weight. Anxious, guilty, and somewhat depressed: about
money, lack of friends. Works 80 hours per week. Describes husband as sexy,
self as frigid, parents as "first class Protestant-Ethickers." Husband verbally
abuses, she withdraws.
Reinforce self-messages that "I am not a hopeless sexual dud" and "my
current lack of sexual feelings doesn't make me a 'frigid person'." Read chapters
in New Guide to Rational Living on self-downing.
Session II
Key Issues
Asked two close female acquaintances to do the sharing-of sexual-histories
portion of homework; felt depressed when they refused at realization she has no
close friends (a group member volunteered to do it with her next week.) Spent
only 20 minutes doing self-exploration, complaining "no time, too fatigued."
SEXUAL ENHANCEMENT GROUPS FOR WoMEN 251
Give self message, "Work for money is important, but work for pleasure is,
too; I have a right to take time for my pleasure."
Complete self-exploration section of homework one time, plus 2 sessions of
Session 2 homework (beginning masturbation). Take 2 one-hour breaks from
work this week.
Session III
Key Issues
Arrived looking unusually glowing and well-groomed, drawing warm com-
pliments from group at which she appeared quite moved. Took long walk for
one of breaks and bought self new dress; feeling much less depressed but still
fearful of starving if she does not keep working. Completed all but one mastur-
bation session and felt "first tingle in years."
Do realistic assessment of work/financial prospects and look for evidence
she will starve in gutter. Examine "payoffs" of starving self emotionally, sexu-
ally, and economically.
Three masturbation sessions with husband out of house. Minimum three
nonsexual self-pleasuring activities every week, henceforth. (E.g., take space for
self by going for walk, visiting a gallery; pleasure senses. by getting a massage,
sitting in sun, rolling in grass, taking long bubble bath.
Session IV
Key Issues
Feeling "more and more sexy," though still masturbated one fewer time
than assignment; completed three self-pleasuring activities and less anxious
about taking time for self. Husband somewhat sabotaging of efforts, attacking
her for weight and unsexiness shortly after she reported feeling pleased at
masturbatory progress. Feeling a bit depressed and self-downing, fearful of
losing husband if she doesn't "shape up."
Remind self that there are many problems, but there are specific things I
can do to work on them. "I can survive and be happy even if my husband does
reject me; I still can find others who will care for me."
Same as above and initiate contact with a possible new woman friend.
Investigate places where she can enjoy an interest and meet new support
network.
Session V
Key Issues
Completed all masturbation sessions, with increasingly pleasurable feel-
ings (felt closer than ever to orgasm, but giving self time). Strengthening faith in
eventually being able to enjoy sex and orgasms. Husband pressuring for partner
sex, despite her indications she would prefer not to have genitally involved sex
with him until further along. Role played how to communicate this more
assertively.
Challenge ideas that if husband says she is unsexy, it must be true; and that
it is awful if he keeps pressuring her.
Respond assertively to husband's attacks and pressuring, after role playing
several more times with another group member.
Session VI
Key Issues
Fallen back on frequency of masturbatory practice, though still experienc-
ing increasingly pleasurable feelings when she does. Somewhat anxious and
depressed about husband's non-cooperation. Considering individual therapy
for self after group ends to carry on some of the good progress she feels she's
made. Still taking time for self-pleasuring and has had dinner with two good
friendship prospects.
Read "Conquering Anxiety" and "How to Feel Undepressed Though Frus-
trated" chapters in New Guide to Rational Living.
Purchase relaxation tape and train self in relaxation procedures. Continue
regular masturbatory practice, experimenting with reading erotic materials,
more rapid and sustained rubbing of clitoral shaft. Recommend possible cou-
ples' counseling to husband.
CASE STUDY 3: MADELEINE
Session I
Key Issues
A 24-year-old computer programmer. Massively self-downing and self-con-
scious. Heavily tied to parents, who still have key to her apartment; and lots of
guilt about sex. On-and-off relationship for two years with an "inconsiderate,
domineering man." Regular sex but no orgasms (she fakes, he does not ask) and
lots of anger and discontent with relationship.
Read at least half of assertiveness book (Your Perfect Right) and give self
message that "I have the right and capacity for sexual pleasure."
Session II
Key Issues
Began report by comparing self negatively to all other members, announc-
ing self as "the group failure." When reminded that she was not supposed to be
"going for orgasm" this week, it emerged she had felt some very good feelings
during self-exploration but did not "count" them.
Write down at least three positive things about self (traits or performances)
each day. Reinforce belief that there is no "one right way to have sex, orgasms;
there's my way."
Session 2 masturbation homework (see pp. 242-243). When anxiety/self-
downing level gets too high, take break to calm self down.
Session III
Key Issues
Had orgasm via manual masturbation, but more involved in upsetness over
urinating when she came. Angry at man friend and ready to break things off.
Father arrived for unannounced visit and she insisted man friend hide in closet.
Role played how to express feelings more assertively with father and boyfriend.
254 SUSAN R. WALEN AND ]ANET L. WOLFE
Had her re-do, in a more self-crediting way, announcement to group that she
had had her first orgasm.
Tell self, "It's O.K. if I urinate when I come-I'm not a horrible freak." Give
self assertion messages: "I am an adult with a right to my own apartment, to
express my feelings and preferences," "My friend is not a condemnable louse
for acting inconsiderately."
Urinate before having sex/masturbating; if necessary, put towel or rubber
sheet over mattress. Experiment with Kegel exercises to see if greater sphincter
control can be achieved. Request that parents never visit without first calling;
speak up to friend about nonsexual things she is upset about. (Role play first
with another friend.)
Session IV
Key Issues
Three more orgasms, better sphincter control. Told parents about wish for
more adult relationship. Spoke to man friend about being neater when he used
her bathroom and showed him clitoris (he had not been clear where it was) by
putting his hand on it. Downing self because not immediately coming in partner
sex.
"It's not awful when things don't go my way, right away." "I am not an
inadequate person even if I never orgasm in intercourse."
Continue to give feedback (nonimpatiently) to man friend about the kind of
sex play and clitoral stimulation she likes. Continue to assert self with parents
and man friend in nonsexual areas. Do shame-attacking exercise.
Session V
Key Issues
Still tending to start each report with self-downing; asked each time to give
self credit for positives and talk about negatives without attacking self. Asked for
and got cunnilingus from friend; let self enjoy it even though she did not come.
Read half of New Guide To Rational Living and challenge idea that when she
fails at something, she is a total failure.
Masturbate in front of man friend to model the kind of stimulation she
likes. "Brag" about self once each day to someone (about something she has
done).
Session VI
Key Issues
Reported in enthusiastic, positive terms first orgasm with partner manual
stimulation; also came close during oral sex. Told friend she "sometimes just
liked to cuddle and hug-without going for orgasms," and he responded well,
without griping. "He's really changing ... listens more." She attributes this to
having tried to express self calmly, without blaming. Would like to try to have
orgasms in intercourse.
Continue to remind self ''I have the right to express my nonsexual (and
sexual) feelings and preferences," "I am an adult."
Continue above assertiveness work; speak to boss about job advancement.
Try stimulating self while partner is penetrating her, experimenting with the
best positions.
CASE STUDY 4: MIRIAM
Session I
Key Issues
A 53-year-old homemaker, married second time, for 12 years; orgasms only
occasionally, via vibrator; downing self for slow progress despite all the reading
she has done. Angry at husband for showing little interest in her sexually; feels
her life "boring."
Give self messages: "Being frustrated is highly inconvenient, but not awful;
just because I'm not enjoying sex much now, doesn't mean I never will."
Session II
Key Issues
Masturbated for one session; but grew so resentful at thought of husband's
sexual withdrawal turned self off and gave up for the week. Impatiently inter-
rupted group members' suggestions with "You don't understand." Leader of-
fered support while pointing out the various ways her low frustration tolerance
was getting her into trouble.
Give self messages: "My husband has a right to act badly; I don't like it, but
I can stand it."
Session 2 homework (see pp. 242-243). Wl;len anxiety level starts shooting
up (or other thoughts/feelings interfere), take a break from self-stimulation and
do relaxation procedures (demonstrated in group).
Session III
Key Issues
Completed three masturbation sessions. Feeling far less hopeless and frus-
trated. Close to orgasm twice, but afraid to "let go, lose control." Desires part-
time job, but afraid of "making a fool of herself" in job interview as she had not
been in job market for 15 years.
Challenge belief that something awful will happen if I orgasm, and that I
must always have perfect control. Anti-awfulize about fudging job interview.
Role play a cataclysmic orgasm, making crazy noises and thrashing around.
Do a "shame-attacking exercise" to desensitize self to fear of appearing crazy,
out of control.
Session IV
Key Issues
Experienced first orgasm in manual masturbation. Did shame-attacking
exercise and one job interview and exhilarated at having taken risks and moved
off dead-center as to a job. Told husband somewhat aggressively that it was

clearly he who had a sex problem and he had better shape up, and he withdrew
further. Group pointed out that anger is sexual turn-off and made several sug-
gestions for new things they might try.
Challenge idea that "my husband must be perfectly sexually cooperative,
right away" and "It's awful/he's awful for behaving this way."
Make a sensual "exchange contract" with husband for a (nongenitally-
involved) "treat" each could give the other and execute contract. Do not make
orgasm the goal.
Session V
Key Issues
Husband agreed to do sensual exchange, then did not initiate it on agreed-
upon night. Miriam withdrew and sulked and depressed self over possibility of
never having good sex with him. Group pointed out her demandingness that he
change instantly and how anger on her part tends to elicit further passivity from
him.
Challenge anger cognitions: "When I assert myself, he must respond
posivitely the first time." Read Increasing Sexual Pleasure with a Partner handout
with husband and get his reactions without attacking.
Reinitiate sensual exchange contract and follow through even if husband
does not initiate it. Express feelings to husband in nonsexual areas without
attacking. Do not go for orgasm.
Session VI
Key Issues
Husband cooperated beautifully in sensual exchange (he nibbled ears and
breasts; she massaged back and buttocks). She initiated sex another time; both
enjoyed it and though she did not come, feels confident she will in time. Re-
ported improved marital communication, with less attacking by her and more
active participation by him.
Keep anti-awfulizing about not always getting desired response from hus-
band. Accept fact that she always may initiate and even prefer sex more than
husband without concluding she must have miserable marriage.
Continue nonresentfully to initiate sensual/sexual encounters. Positively
reinforce husband for assertive behavior and sexual initiation. Join assertiveness
group to improve personal and vocational communication skills.
CONCLUSION
In a society where a good deal of female sexuality has been based on

externally defined criteria (largely by males), all-women's sexuality
groups are seen as a powerful way of helping women redefine their own
sexuality and determine the form of their sexual expression. In an
important position paper on women's sexuality (Childs, Sachnoff, &
Stocker, 1975), written in collaboration with the Association for Women
in Psychology, the characteristics of the sexually self-affirmed woman
were summarized. The self-affirmed woman "is a woman who: (1) can
enjoy her own body apart from others ('I have a primary sexual relation-
ship with myself'); (2) can have sexual experiences for her own reasons;
(3) can experiment and experience; (4) has her own standards and uses
herself as the measure of her own experience. The self-affirmed woman
understands the interpersonal issues found frequently in relationships
that are sexual. She knows ways to negotiate, to fight, to settle, and to
forgive. She knows when to leave relationships that are too costly."
Although these goals are rarely perfectly accomplished, it is our
observation (Wolfe, 1976) that cognitive/behaviorally oriented sexual en-
hancement groups provide a corrective emotional experience and ac-
complish an impressive range of results in a relatively short time period.
Sexual re-education, a climate of openness and support, and skills teach-
ing (e.g., assertiveness training) are important ingredients in this pro-
cess. It is the cognitive focus, however-the teaching of general anx-
iety-, anger-, and depression-combatting philosophies-that is seen as
being particularly responsible for helping the women develop an ex-
panded set of skills for more clearly defining and pursuing their sexual
preferences.
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Wolfe, J. A cognitive behavioral approach to female sexuality and sexual expression. Paper
presented at the annual convention of the American Psychological Association, Wash-
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Wolfe, J. How to be sexually assertive. New York: Institute for Rational Living, 1976.
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Yalom, I. D. The theory and practice of group psychotherapy. New York: Basic Books, 1970.
12
One's Company; Two's a
Crowd
Skills in Living Alone Groups
LAURA PRIMAKOFF
INTRODUCTION
In our culture it is permissible to say you are lonely, for that is a way of
admitting that it is not good to be alone . . . and it is permissible to want to
be alone temporarily to "get away from it all." But if one mentioned that he
(she) liked to be alone, not for a rest or an escape, but for its own joys, people
would think that something was vaguely wrong with him (her)--that some
parriah aura of untouchability or sickness hovered around him (her). And if a
person is alone very much of the time, people tend to think of him (her) as a
failure, for it is inconceivable to them that he (she) would choose to be alone.
(May, 1953, p. 26)
Singleness and living alone are rapidly growing phenomena in our soci-
ety (Stein, 1976). This is reflective of changes in life-style and values
taking place on a societal level in the United States. Our society is begin-
ning to experience some dramatic structural changes in the nature of
people's social relationships and living arrangements that entail more
and more people living outside the traditional context of marriage and
romantic love; 1 of every 5 American households consists of just one
person (Going it Alone, September 4, 1978, p. 76). (This figure does not
include the sizeable number of single-parent households.) This may
represent a type of sociological evolution in the latter part of the twen-
tieth century, when for a variety of social, cultural, and economic rea-
LAURA PRIMAKOFF • Center for Cognitive Therapy, Department of Psychiatry, 133 South
36th Street, University of Pennsylvania, Philadelphia, Pennsylvania 19104.
261
262 LAURA PRIMAKOFF
sons, for a growing minority of the population, the individual con-

stitutes the social unit, rather than the family or the couple.
There are a number of diverse populations for which the issue of
living alone clearly has relevance. The young never-married, the di-
vorced, the widowed, the elderly, and various types of formerly institu-
tionalized individuals, including ex-mental patients.
The present chapter will present a cognitively focused, multimodal
treatment approach to living alone. The program is based on a treatment
manual developed in conjunction with an empirical exploration (Pri-
makoff, 1981) of what constitutes the functional cognitive schemas
(Beck, 1976) as well as behaviors of those people who are able to live
alone contentedly versus the dysfunctional cognitive schemas and be-
haviors of those people who experience chronic loneliness and dissatis-
faction when living alone.
There is virtually no theoretical or empirical work with regard to
contented aloneness in the psychological literature. Existing descrip-
tions of such a state are found in anecdotal and biographical accounts,
case histories, novels, and poetry. However, the growing importance of
aloneness and singleness from both the psychological and sociological
viewpoint is beginning to be realized. As a result, psychological investi-
gation of those individuals who either choose or find themselves single
or living alone has begun (Kangas, 1977; Kanter, 1977; Kelly, 1977; Par-
melee & Werner, 1978; Shaver & Rubinstein, 1979).
There are, however, a number of psychologists (Altman, 1975; Ittel-
son, Proshansky, Rivlin, & Winkel, 1974; Lilly, 1977) who have sug-
gested that humans may have a need for privacy and that experiences of
solitude can provide a variety of important benefits ranging from relaxa-
tion and emotional release to profound personal, philosophical, and
creative insights. Lilly (1977) and Suedfeld (1981) have described the
use of isolation as a treatment intervention for a variety of clinical prob-
lems.
Several areas of literature provide material suggestive of what might
constitute contented aloneness. First, experimental and anecdotal ac-
counts of sensory deprivation and extreme isolation experiences
(Brownfield, 1972; Deaton, Berg, Richlin, & Litrownik, 1977; Zucker-
man, 1964) suggest that individuals who are able to engage in various
forms of cognitive, affective, and behavioral self-stimulation cope better
in such circumstances. Second, several theorists (Ellis, 1962; Maslow,
1968) have proposed that those individuals whose self-esteem and basic
life satisfaction are not contingent upon love and intimacy, but rather
upon their own cognitive, behavioral, and affective resources, are more
developed emotionally.
ONE's CoMPANY; Two's A CROWD 263
Central to an "alone-contented" cognitive schema is the belief that

romantic love and intimacy are not required for happiness, satisfaction,
or meaning (Primakoff, 1981). Individuals with such a schema are likely
to have a more balanced and accurate view of the advantages and disad-
vantages of both intimacy and aloneness. When such individuals find
themselves living alone, they are more able to focus on the advantages
of that situation, thereby deriving satisfaction from it, even though their
ideal preference might be to be involved in an intimate, love relation-
ship.
When living alone, the alone-contented group has the ability to
create for themselves a pleasurable and satisfying internal and exter-
nal world. Such individuals have a range of activities and experiences
engaged in alone and with others that may provide them as much or
more satisfaction and involvement as does romantic/conjugal intimacy
and commitment. In the absence of intimate love relationships, these
important alternate sources of gratification very well may serve as
sources of positive feeling in order to remain generally satisfied with the
life-style of living alone and as powerful buffers against severe lone-
liness.
Cognitive-behavioral clinical work (Beck, 1976; Beck, Rush, Shaw,
& Emery, 1979; Ellis & Harper, 1975; Lazarus, 1976; Meichenbaum, 1977)
has demonstrated that it is possible to replace dysfunctional thinking
and behaving with more adaptive cognitive and behavioral coping strat-
egies. The goals of the current treatment program are to help individuals
living alone systematically to develop an alone-contented cognitive
schema as well as behavioral "solitude" skills for living alone.
The program has been conducted both as a therapy program and as
an educational-enrichment program. Certain of the techniques, strat-
egies, and homework assignments would need to be adapted to the
specific clinical and/or socioeconomic needs of the particular group
members. However, the basic principles are relevant for all individuals
living alone. Thus far, the program has been successful in helping indi-
viduals of varying psychiatric diagnoses, socioeconomic status (SES),
ages, past and current marital status, sexual orientation, with or without
children living at home, and so forth. In addition, there have been a
number of married individuals who have benefited from learning how
to spend higher quality time separately from their spouses.
The cognitive and behavioral skills involved in tolerating and enjoy-
ing experiences alone are central to issues of autonomy versus social
dependency in general. Thus, the treatment program addresses con-
cerns that very well may be relevant to syndromes as seemingly dispa-
rate as agoraphobia, depression, and marital distress.
264 LAURA PRIMAKOFF
The program consists of 10 sessions conducted on a weekly basis;

each session lasting 2Vz hours. The remainder of the chapter will be a
session-by-session description of the group program.
SESSION 1: INTRODUCTION AND RATIONALE
The group experience begins by the leader or leaders introducing

themselves in terms of basic demographic information: their own alone-
ness history, their own romantic/marital relationship history, and their
reasons for being interested in leading the group.
I have found that this type of self-disclosure serves to model self-
disclosure by group members and to begin to present the leader(s) as
successful role model( s) in terms of living alone. My experience has been
that in order to be able to lead such a group it is important for the
leader(s) to have had some previous successful experience at living
alone and to value that experience in its own right.
Group members then are requested to turn to the person sitting
next to them and interview him or her for 10 minutes regarding the same
kinds of information presented by the leader(s), that is, aloneness and
relationship history, and why he or she came to the group. The process
is then reversed and the interviewee now interviews his or her partner.
Then each person introduces the partner and presents the most
relevant information with regard to him or her to the group. This is a
fairly open-ended structure in that the person being described is free to
add any comments and the leaders can ask additional questions in order
to better understand and clarify the presentation.
The leaders then explain how inherent in the content and goals of
the program is a questioning of both societal and members' personal
assumptions concerning what life goals, values, types of social relation-
ships, and living arrangements constitute normality and optimal psy-
chological functioning. An increasing number of individuals find them-
selves living alone for the first time in their lives. However, many of
them never have learned the requisite psychological and/or practical
skills to live alone in a competent and satisfying manner. Traditionally,
the assumption has been that living alone is an inherently undesirable,
lonely, and temporary state to be escaped by the forming of relation-
ships with other people, in particular, a romantic love relationship.
However, the unique focus of this program is on one's relationship with
oneself, and the development of one's own resources which can serve as
supplements and alternatives to external relationships.
The "paradigmatic shift" being suggested is that singleness is a
legitimate, alternative life-style, and that short- and long-term experi-
ONE'S CoMPANY; Two's A CROWD 265
ences of solitude provide unique benefits. It is suggested that one of the

purposes of a group for those living alone is to bring singles together
"out of the closet" in order to affirm that they constitute a significant
demographic proportion of the American adult population, in terms of
numbers, as well as economic and cultural influence. Such an affirma-
tion helps in countering the self-concept of being freakish, marginal,
and alone in one's life-style, as well as the notion that "everyone else" is
married and coupled.
The following points constitute the rationale for the program:
1. The major goal of the program is for members to develop an
intimate, loving, and accepting relationship with themselves; such a
relationship involving the same kind of active process as developing an
intimate relationship with another person, for example, the adoption of
certain caring attitudes and behaviors, having a variety of meaningful
and pleasurable experiences, and so forth.
2. In order to try to shift the attitudes and behaviors that one has
practiced and had strongly culturally reinforced for 20 years or more, as
powerful and systematic a change process as possible will need to be
implemented.
3. A multimodal approach to change is introduced (Lazarus, 1976).
The central notion of this approach is that clients experience dysfunction
and dysphoria in their solitary and/or social behaviors, emotions, sensa-
tions, visual images, thoughts, and attitudes. In order to solve global
and diffuse presenting problems effectively, a comprehensive and thor-
ough assessment must be made within each of these modalities so as to
be able to isolate the precise maladaptive habits and/or response deficits
that are interfering with adaptive functioning. One then proceeds to
teach the necessary competencies and coping skills within each of the
modalities.
4. In order to change the overall quality of one's time alone and the
experience of aloneness, one needs to change a variety of areas of func-
tioning. However, since this is a cognitively focused multimodal pro-
gram, the cognitive model of emotional distress and change is particu-
larly emphasized. The basic notion is that one's internal world, that is,
one's thoughts and images about aloneness and singleness, influence
one's feelings and behavior to a great extent. The focus of much of the
program will be the identification, questioning, and changing of dys-
functional thoughts about being alone.
5. The following list of the 10 sessions of the program is distributed
and discussed.
Session 1: Introduction and rationale
Session 2: Aloneness and loneliness
266 LAURA PRIMAKOFF
Session 3: Love, sex, and approval "needs"

Session 4: Daily domestic living
Session 5: Being at home with yourself
Session 6: Going out with yourself
Session 7: Relationships with others
Session 8: Open session
Session 9: Developing a physical, sensual relationship with
yourself
Session 10: Unique advantages and opportunities of the single life-
style
6. Lastly, the various methods for systematic skills training and
problem solving are presented, for example, aloneness journal and re-
cord keeping, cognitive and behavioral homework assignments, bibli-
otherapy, environmental interventions, and behavioral contracts. It is
explained that as leaders we offer a number of resources, such as, dis-
cussion of ideas, sharing of experiences between group members, bibli-
otherapy, and various cognitive and behavioral change techniques. In
terms of the actual change, however, it is a function of the extent to
which group members implement and practice the various techniques
that are presented.
Homework
The didactic portion of the session is followed by a relaxation exer-
cise that is done in order to model a self-instructional, self-control pro-
cedure that group members can use to counter anxiety, fears of loneli-
ness, and so forth. Relaxation instructions (Lazarus, 1971, pp. 273-275)
are distributed so that participants can practice relaxing at home.
The first homework assignment for this session is to keep an alone-
ness record (Table 1), which consists of daily recording of the start and
end of time alone, where one was, what one was doing, what one's
mood was (put the first letter of mood word), and what one was think-
ing at the time, the actual sentences or images.
The second assignment is to formulate two cognitive or behavioral
goals to be worked on during the therapy program. These are to be as
realistic and specific as possible. Examples are:
1. I want to be able to go to the movies alone on a Saturday night.
2. I want to be able to have a dinner party in my home.
3. I want to believe that I can provide myself with some of my own
happiness and meaning.
ONE's CoMPANY; Two's A CRowo 267
TABLE 1
Aloneness Recorda
Name __________________________________________________________________
Day and d a t e - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -
Time
Start End Place Activity Mood I> Self-talk
6-12
12-5
5-9
9-12
"Adapted from Hawkins, Setty, and Baldwin (1977).

''Neutral, Content, Lonely, Angry, Depressed, Happy, Bored, Tired, or Unfocused.
268 LAURA PRIMAKOFF
4. I want to change the attitude that friends are worth less than
lovers.
SESSION 2: ALONENESS AND LONELINESS
All of the sessions in the program are structured similarly. First, the
leaders ask if there were any reactions to the previous session and these
are discussed. Secondly, the homework assignments are handed in and
any reactions or questions regarding them are discussed. The leaders are
to read assignments between sessions in order to gain an understanding
of members' aloneness and to provide any useful feedback to them.
Thirdly, either written materials, verbal didactic material, or experiential
exercises are used to generate discussion of participants' thoughts, feel-
ings, and experiences with regard to the various topics addressed in the
program. When a particularly illustrative or problematic personal issue
is raised, the leaders use a variety of cognitive restructuring techniques,
such as suggesting more plausible explanations for an event or contra-
dictory evidence that questions a particular belief, in order to model how
one can begin to change one's thinking. It often can be very effective for
the leaders to elicit material from group members so that they offer each
other the above kinds of alternatives, rather than their always being
suggested by the leaders.
A questionnaire about loneliness is then distributed. Group mem-
bers spend 10 to 15 minutes writing their answers to the following
questions, which are then used as the basis for discussion:
1. What is the difference between aloneness and loneliness?
2. What kinds of situations make you feel lonely?
3. Are there certain times of the day, week, or year when you feel
particularly lonely?
4. What exactly are your thoughts, visual images, and feelings
when you're lonely?
5. What are your worst fears and fantasies about being alone?
6. What do you do when you feel lonely? How successful are your
attempts to reduce loneliness?
In the discussion that follows, the following distinctions have
proved useful:
1. "Aloneness" involves being with oneself, physically separate
from others. (a) It is a neutral or potentially positive experience. (b)
Some of the potential, positive aspects of solitude involve contented
relaxation, self-awareness, and enjoyable absorption in activity and
creativity.
2. "Lonesomeness" involves times when one is alone, but would

prefer to be with others (Johnson, 1977).
3. "Loneliness" involves focusing on the discrepancy between the
social relationships that one has and those that one believes one "should"
or "must" have (Perlman & Peplau, 1981; Young, 1982). Such a focus then
creates the following types of distorted and distressing thinking:
• A negative distortion of the relationships that one has: (a) Magni-
fication of the discrepancy-"! feel totally alone in the world."
"Everyone has deserted and abandoned me." (b) Discounting the
number or quality of current relationships: "No one cares about me
or is really interested in my life." (c) Dichotomizing relationships
into romance versus "nothing": "My friends are okay, but I need a
lover." Without a lover, I'm completely alone."
• Extending the discrepancy into the past and future: "I've never
really been loved." "I'm afraid I'll always be alone." "I'll never find
anybody as good as X again." (e.g., hopelessness).
• Low frustration tolerance, for example, demanding that things be
the way one wants them to be: "I can't stand being alone." "I
shouldn't have to be alone." "I can't stand not having someone who
loves me."
• Self-downing: "It's my own fault that I'm alone." ''I'm worthless
and unlovable."
There is then a "secondary"loneliness that involves the following
kinds of dysfunctional thinking in reaction to experiences of loneliness:
• Anxiety and low frustration tolerance about the loneliness: ''I'm
afraid these feelings are never going to go away." "I can't stand
these feelings."
In discussing this type of anxiety, the point is made that it"is not
being alone that people are afraid of, because there is nothing
"dangerous" about being alone; rather, people are afraid of their
own painful thoughts and feelings when alone.
• Further self-downing and shame for being lonely: "There must be
something wrong with me feeling so lonely." "The only people out
there are rejects like me." "Hardly anyone is as lonely as I am." "I
am neurotic and screwed up for being lonely." This latter self-de-
precating thinking causes even further feelings of isolation and
alienation, and so the lonely feelings continue to escalate.
Homework
The first homework assignment for this session involves focusing
on feelings of loneliness in the aloneness journal. The purpose is to
270 LAURA PRIMAKOFF
identify: When do I begin feeling lonely? What triggers it? How long
does it last? Was I with a particular person? What was I thinking about?
What helped to reduce it?
The second assignment involves attempting to identify the mos·t
distressing or frequent dysfunctional lonely thought and beginning to
question its validity. In addition, participants design behavioral experi-
ments to test some of their secondary loneliness reactions, for example,
to increase tolerance of loneliness, force oneself to be alone and lonely
for a certain period of time; to decrease shame about being lonely, not; to
obtain information by asking other people about their loneliness, and so
forth.
Some time is spent individually tailoring the second assignment.
Homework sheets describing the assignments and respective behavioral
contracts are distributed. (This is the format for homework for the re-
mainder of the sessions.) The contract states, "If I do homework assign-
ment Number 1, I will give myself _ _ ." "If I do not do homework
assignment Number 1, I will either deprive myself of _ _ or make
myself do--·"
Lastly, in order to further understanding of the cognitive model of
emotional disturbance, two pamphlets are distributed, Thinking and De-
pression (Beck, undated) and Coping with Depression (Beck & Greenberg,
1974).
SESSION 3: LOVE, SEX, AND APPROVAL "NEEDS"
After discussing the kinds of maladaptive lonely self-talk that group

members recorded during the week, the concept is presented that these
kinds of distorted thoughts proceed from certain underlying dysfunc-
tional assumptions regarding love, sex, and approval that are both per-
sonally and culturally based.
Obviously, there are a variety of types of human love relationships.
In our culture, however, there is a societal/media overvaluing and pre-
occupation with one particular form of love; that is, the romantic, sexual
form that culminates in marriage. The unfortunate consequence for
many individuals of this cultural obsession is that romantic and conjugal
relationships are overburdened with many functions and meanings that
they cannot possibly fulfill. Many individuals have the unrealistic expec-
tation that social relationships in general, but in particular romantic love
relationships, can and should be the providers of their worth, self-es-
teem, identity, meaning, happiness, excitement, and intimacy. When
love becomes the sole source of gratification in such a pervasive and
profound way, one literally needs the external loved one to maintain
ONE's COMPANY; Two's A CROWD 271
one's emotional equilibrium. Love and Addiction (1976) by Stanton Peele

is recommended reading for a vivid description of the parallels between
this type of needy love and substance addictions.
At this juncture, the "alone-deficit" paradigm is described ex-
plicitly. Central to such a paradigm is the need for external others to
provide love, stimulation, and meaning in one's life. Because of the
demand for others to fulfill these functions, substitutes are not possible.
The underlying theme in the alone-deficit schema is that the benefits of
romantic intimacy in particular are overfocused on, exaggerated, over-
valued, and demanded. In turn, the potentially gratifying aspects of
objective reality both in terms of actual social relationships and experi-
ences alone are to varying degrees ignored, minimized, devalued, and
experienced as inherently incomplete, deficient, and unsatisfying.
Clearly, this pattern of living alone results in extreme vulnerability to
experiences of loneliness. Another negative consequence of this exagge-
rated emphasis on the necessity and desirability of romantic love and
sex is that individuals living alone often conclude that they should want
love and sex and that if they do not, for whatever length of time, there is
something wrong with them.
The alternative "alone-contented" paradigm is then presented
again, that is, the belief that one can be happy and satisfied living alone
without romantic love and intimacy. In order to concretize and strength-
en the alone-contented assumptions, an excerpt from the chapter
"Tackling Dire Needs for Approval" (pp. 92-98), from A New Guide to
Rational Living (Ellis & Harper, 1975), is distributed. The entire book is
recommended reading as is Feeling Good (Burns, 1980). The selected
excerpt questions philosophically and logically the idea that one's self-
esteem and happiness are contingent on others' love and approval and
suggests some more adaptive assumptions and behaviors. In order to
provide additional specific suggestions, the following materials are
given to participants and discussed with regard to the homework.
Cognitive and Behavioral Strategies for Reducing Loneliness;

Love and Sex "Needs"
Behavioral Strategies
The guiding principle is to plan ahead. Have a list of activities that

you know you enjoy doing and that help to reduce your loneliness.
1. Plan ahead for evenings, weekends, trips, and holidays so that
there are enough activities and people for you.
272 LAURA PRIMAKOFF
2. Help someone else or something else; focus on loving rather

than on being loved, for example, volunteer work, friends, or
pets.
3. Write letters, visit friends, call local or long-distance friends.
4. Go out and do something pleasurable by yourself; for example,
go to the movies, go shopping, go for a drive, take a walk.
5. Engage in some kind of physical recreation by yourself, for ex-
ample, work with your hands, dance, engage in sports, or
exercise.
6. Do some kind of physical or mental work by yourself, for exam-
ple, clean up your home, study, do personal or job-related work.
7. Engage in some form of creative self-expression, for example,
write in a journal, talk to yourself, sing, play music, draw or
paint.
8. Keep a scrapbook of poems and advice; engage in spiritual ac-
tivities, or religious or philosophical thinking that is comforting
and meaningful to you.
Self-Talk Responses
1. Think about possible benefits of your experience of loneliness,

such as telling yourself that you are learning to be self-sufficient
or that you will grow from the experience.
2. People have survived for years by themselves.
3. I would rather be with someone tonight, but being here alone is
okay.
4. Just because I'm alone now doesn't mean I'll always be alone.
5. I care about myself.
6. There are people who care about me (list them in your mind:
family, friends, and so forth).
7. There are activities that I enjoy alone and things that are mean-
ingful and important to me (list them in your mind).
8. Everybody gets lonely at times, even married people.
9. Just because this man or woman has rejected me does not mean
they all will.
10. I won't die if I don't have sex tonight; I'll just be frustrated.
11. Remind yourself that you actually do have, or again will have,
good relationships with people.
12. It is not so important to be liked by everyone.
13. It's all right at this point in my life not to be romantically in-
volved.
14. Think about things that you are good at doing and qualities that
make you attractive to others.
Attitudinal Alternatives
1. Focus on the advantages of living alone and not being involved

in a romantic love relationship: (a) Living alone I have more time
and emotional energy for myself. (b) Living alone I can feel freely
and express my emotions. (c) There are many interests and plea-
sures that I engage in alone that are meaningful to me. (d) Living
alone I can be involved with many different people in many
different ways. (e) Living alone I can decide when I do and do
not spend time with others. (f) There are some unique, exciting
experiences that one can have living alone. (g) Living alone I can
discover and develop my own values, beliefs, and interests. (h) I
still can love; the less I have to be loved, the more energy I have to
love others. (i) I can use this opportunity to increase my frustra-
tion tolerance for not getting what I want, that is, love.
2. Remind yourself of the disadvantages of being with people
and/or involved in a romantic relationship. List in your mind the
specific reasons that your last major relationship ended; remind
yourself of all of the problems and heartaches.
3. Dispute the belief that only love gives meaning and happiness to
your life: (a) Focus on the fact that you are living alone and
functioning quite well. (b) The source of your enjoyment of life is
in you, not in other people. (c) I have a commitment to my own
growth and development. (d) I can be happy, even if for a long
period of time I am not involved in an intimate love relationship.
In order to do the homework, the following example is handed out
to help demonstrate how to answer one's lonely self-talk or automatic
thoughts with more reasonable and realistic responses.
Homework
The first homework assignment for this session involves focusing
on feelings of "needing" others' love and approval in the aloneness
journal. The purpose is to identify: Who or what triggers these feelings?
With which people or in what kinds of situations am I particularly
needy? What are my thoughts? How can I begin to answer them more
reasonably?
274 LAURA PRIMAKOFF
TABLE 2
Daily Record of Negative Automatic Thoughtsa
Date Situation Emotion(s) Automatic thought(s)
5/23 At home, read- Sad; miserable; aban- Why didn't he call? Why
ing-waiting for Bob to doned; lonely is he rejecting me? I
call-it's now 10 feel so miserable, I
P.M.-he hasn't called don't know what to
do-why does this al-
ways happen to me--l
just can't go on like
this-what did I do
wrong?
Questioning the evidence Alternative therapy

Reasonable/adaptive response Reasonable/adaptive response
Just because he didn't call doesn't mean There could be many reasons why he
he is rejecting me-l already saw him didn't call-besides rejection! He
twice this week-if he didn't like me could be tied up with his clients, he
he would not have spent that much could be trying to set bail for some-
time with me-l shouldn't jump to one--it may have skipped his mind-
crazy conclusions like that-and it's he could be with friends-he may
not true that "this" always happens to have had something to do. But even if
me. With John, I was the one who he is having second thoughts about
didn't want to keep up the me--we could talk about it-it doesn't
relationship!! automatically mean that I can't hold
on to him.
Re-attribution De-catastrophizing
Reasonable/adaptive response Reasonable/adaptive response
Why should I assume that his not call- Here I go again! Thinking that I am
ing has to do with me?? He may have rejected!!-But even if I am (which I
a lot of reasons for doing what he don't really know for sure) even if he
does-things that may have nothing to doesn't want to see me--it's not true
do with me. It doesn't make sense to that I can't go on!! It's just a feeling I
think that everything happens behave. I have survived before even if
cause of me-that I did something this doesn't work-the worst that can
wrong. He must have his own feel- happen is that I'll be sad, unhappy
ings, ideas, and fears just like I. If but it's not the end of the world-
things don't work out the way I'd like there are other men out there, and I
them-it could be because of his own have my friends, my job-1 can go on.
things-it doesn't make sense to be-
lieve that I am solely responsible for
what happens between the TWO OF
US!!
•From Kovacs. Copies available from The Center for Cognitive Therapy, Room 602, 133 South 36th
Street, Philadelphia, Pennsylvania 19104.
The second assignment involves identifying a central dysfunctional

assumption and spending 10 to 15 minutes per day questioning its
usefulness and/or validity in writing. Examples of such core beliefs
would be "Love gives me worth." "Love gives meaning to my life." "I
must have love."
Lastly, the following kinds of suggestions are made for cognitive
and/or behavioral practice. These serve to generate experiential evi-
dence directly counter to the unreasonable thinking.
1. Take interpersonal risks, e.g., act in ways you want to act with
someone whose approval you want; try to get a person who
might reject you interested in you-see if you survive.
2. Date several people at once.
3. Focus on others, rather than being obsessed with how they are
reacting to you.
4. Practice thinking about being rejected or about a relationship
that you're involved in ending, and see if you can alter your
automatic thoughts and feelings; try to calmly imagine your
lover being with other people.
SESSION 4: DAILY DoMESTIC LIVING
Group members fill out the following questionnaire and give it to

the leaders. Usually, the two or three topics of majority concern are
chosen to be discussed.
Circle the topics that you would find the most useful to discuss
today:
1. Home:
a) choice of place to live
b) housekeeping: cleaning, laundry
c) decorating and furnishing
d) cooking for yourself
e) entertaining at home
f) physical safety
2. Maintenance:
a) car maintenance
b) house maintenance
c) self-grooming, personal hygiene, physical health care
3. Problematic habits:
a) overeating
b) excessive drinking
276 LAURA PRIMAKOFF
c) excessive "recreational" /self-medication drug use

d) financial mismanagement
e) time mismanagement, for example, overextending oneself;
procrastination; wasting time
4. Other daily domestic life issues that have not been listed
In this session it is suggested that in order to create a self-sufficient
and autonomous life-style for oneself it is important to develop a variety
of "solitude skills." The most fundamental and critical ones, upon
which all others are contingent, involve creating a daily life for oneself
that is as high quality and enjoyable as possible, in which one takes care
of basic domestic and maintenance needs.
The following question calls attention to the kind of "alone-de-
prived" existence that many individuals living alone create for them-
selves: How long would you live with someone when all you had was
bad meals, for example, tuna from out of the can, TV dinners; the place
was always a mess; most of your spare time was spent watching TV and
listening to the radio; when you hardly ever went out or did anything at
home that was fun or interesting? (One group member "jokingly" an-
swered, "Would you believe ten years?")
The following general principles provide an overall framework for
the discussion of specific domestic topics: One's goal with regard to
domestic, daily maintenance of one's life is mastery and self-sufficiency.
In order to achieve such a goal, it is necessary to do a systematic task
analysis of each problem so as to decide which combination of the fol-
lowing possibilities will solve the problem most effectively and efficient-
ly:
1. If one wants to solve the problem oneself: (a) learn the necessary
skills and information through a variety of methods: self-help
books, courses, friends, service people.
2. If one cannot or does not want to solve the problem oneself: (a)
learn how to find and enlist the necessary resources to do so; (b)
be more assertive with service people and friends by asking for
help and learning from them.
When one has been part of a couple there often has been a sex-role
based division of skills and knowledge. Thus, one's partner may have
possessed certain skills that now have to be found elsewhere. However,
it is important to realize that even as a couple you both lacked many
skills for which you had to depend on others. As a result, once one
develops the attitude and capability of finding help, being alone con-
stitutes much less of a realistic deficit of skills than ordinarily is thought.
What is very apparent, however, is that whatever tendencies involving
lack of confidence, assertiveness, self-caring, or self-control one had

while living with another often can become intensified when living
alone. There is none of the daily support and structure that often is
provided by a conjugal relationship. You must create this for yourself.
It is beyond the scope of this session as well as the current chapter
to discuss all of the domestic topics. However, some of the highlights of
"alone-contented" domestic attitudes and behaviors will be presented
here. Group members often will offer each other very ingenious sug-
gestions and solutions to problems.
Home
Creating a high quality home life for oneself involves self-caring and
self-expressive attitudes. The kinds of dysfunctional thinking that inter-
fere with creating a nurturant and expressive home are: "Why bother,
it's only me." "Why set up house when I don't want to be living alone?"
"I have terrible taste anyway." "What will other people think if they see
my place?"
One should do whatever is needed to create a home for oneself,
physically and emotionally, so that it is a place to which you look for-
ward to spending time with yourself as well as entertaining others. It is
important for your home to be as comfortable and personally expressive
as you would like it to be. This is one of the luxuries of living alone; you
do not have to have anything that you do not like in your home. As your
tastes change, you can change the decor. Inherent in decorating and
taking care of one's place of residence is that one is making an ex-
pressive statement as to one's tastes and who one is, as well as at least
some minimal commitment to being single. (Some individuals will
choose to spend years living alone in an undecorated home because of
the attitude that their situation is only a "temporary" one.)
In terms of comfort and pleasure, you can give yourself extrava-
gances selectively, for example, flowers, a nice bed with decorated
sheets, a full length mirror, or a good stereo. You can surround yourself
with possessions that are meaningful and comforting to you, such as,
pets, plants, your own or friends' paintings, or photographs.
Eating
Cooking for oneself and eating alone present difficulties for many
individuals living alone. Often it is a lack of self-caring as well as an
278 LAURA PRIMAKOFF
avoidance of feelings of loneliness that cause many people to either

avoid eating by themselves or to make it a "quick and dirty" affair if they
do. People often believe that one should not eat alone because eating is a
social activity. However, eating alone has many of the same advantages
as engaging in other activities alone, for example, flexibility and experi-
mentation (time, choice of food), and increased intensity and focus on
the experience itself.
There are numerous methods for making eating alone as pleasant as
possible, such as being physically comfortable when you eat; having
comforting and favorite foods and some good knives and wine glasses.
For special occasions, one can indulge in candlelight, a glass of wine,
breakfast in bed, or order in food. Cognitive/attentional strategies to
counter loneliness and feeling the need for someone to eat with include
listening to good music or reading while you eat; giving yourself time to
relax and think about the day; appreciating the fact that you have made
yourself a nice meal; really focusing on the taste of the food, rather than
having your attention divided between talking to someone and eating.
Problematic Habits
Group members sometimes are reluctant to disclose that they may
have a particular problem, such as excessive drinking or binge eating.
There are several approaches that I have found to be helpful in defusing
the shame associated with such problems. First, one provides a compas-
sionate acknowledgement that those living alone are understandably at
particular risk for having some of these problems, but that it is important
to remember that many of those who are married also suffer from such
difficulties. Second, a matter-of-fact problem-solving approach is sug-
gested, wherein one's task is to employ the appropriate combination of
cognitive, behavioral, and environmental interventions to solve the
difficulty.
If one first examines the kinds of events, thoughts, and feelings that
trigger the behavior, one can begin to see patterns of functions that the
behavior may serve. A frequent function is that of "self-medication," in
terms of reducing or avoiding the experiencing of unpleasant emotions
such as anxiety, depression, and loneliness. The problem behaviors can
range from excessive drinking to oversleeping to "workaholism." An-
other function is that of providing maladaptive forms of "pleasure," for
example, overeating, drinking, or "interest," such as, shopping (over-
spending) or watching television.
There are several kinds of dysfunctional thinking that maintain
such behaviors. First, there are varying degrees of denial as to the conse-
quences of one's actions, for example, "It doesn't matter, it's only me
(how fat I am, how chaotic my life is)." One can more easily think of
oneself as being invisible and no one else knowing or caring how one
looks or acts. A second problem is low frustration tolerance, for exam-
ple, "I can't stand eating less, having a schedule, cleaning up." Third,
there may be shame as well as hopelessness about changing: "This is the
way I am." "I can't control myself." "I'd be too lonely and unhappy if I
didn't." Lack of knowledge regarding self-help methods and groups
contributes to the feelings of isolation and hopelessness.
Homework
The homework assignment for this session involves choosing one
aspect of daily living that one would like to begin changing. Individually
tailored assignments involve whatever techniques are appropriate, for
example, record keeping, information gathering about services, and so
forth. Group members are informed of numerous self-help books re-
garding domestic tasks and problems, some of which are written ex-
pressly for those living alone, for example, The I Hate to Housekeep Book
(Bracken, 1962); Cooking for One is Fun (Creel, 1976); Living in One Room
(Narr & Siple, 1976); The Reader's Digest Complete Do-It-Yourself Manual
(1981).
SEssioN 5: BEING AT HoME WITH YouRSELF
In order to encourage interaction between group members in this

session, groups of three or four are formed in order to discuss their
responses to the following questions:
1. What kinds of things did your mother or father do for you that
were especially comforting (e.g., chicken soup, warm baths.)?
2. What kinds of things did you enjoy doing alone when you were
growing up?
3. Think of the friends and lovers you have had who have been
really interesting and enjoyable to be with. What kinds of things
did they do that were interesting and exciting to you? What
things did you do together that you enjoyed? What made the
relationship of high quality?
4. What are some interests and/or pleasures that you would like to
pursue alone?
280 LAURA PRIMAKOFF
The conceptualization that is introduced in this session is that when

living alone one can con~truct as high a quality relationship and life-style
with oneself as with a spouse or cohabitant. The development of a
relationship with yourself involves making a serious commitment to
yourself and to your own self-development. This is achieved largely by
providing for yourself the functions that other people ordinarily serve.
Friends, family, and romantic partners provide nurturance, caring, in-
terest, love, excitement, and fun; teachers, religious counselors, and
therapists facilitate personal and spiritual growth. It is inherent in creat-
ing a primary, intimate relationship of this kind with oneself that one
takes on a dual emotional and behavioral role involving being a compan-
ion to oneself, that is, the caretaker and the cared for.
The next question to be addressed is: What constitutes any high
quality relationship and life-style? There are at least three necessary
components: (1) everyday quality, that is, the kinds of domestic and
maintenance issues discussed in the previous session, (2) ongoing in-
terests and activities, and (3) special times. One's relationship with
oneself is no different from a romantic/conjugal relationship in that it is
vulnerable to boredom and stagnation in the absence of sufficient stim-
ulation. People sometimes have a tendency to allow their relationships
to "slip." They start taking each other for granted; their time together
deteriorates into low-quality time. The same process all too easily can
happen with yourself.
The idea being suggested is that you give the same commitment
and caring to yourself that you would to a loved one on a daily basis. In
order to develop ongoing interests and activities, as well as have special
times, it becomes necessary to set aside regular times during the week
for yourself, for example, "Monday and Wednesday nights are for me,"
the way you would for a lover. In order to do this, one has to be willing
to risk other peoples' negative reactions to your wanting to spend time
with yourself.
The remainder of the session is a discussion of the advantages and
positive attitudes involved in choosing to spend time at home with
yourself.
Initially, group members are encouraged to recall "forbidden" or
"discouraged" activities engaged in when parents, roommates, or
spouses were not home, in order to remind themselves of the playful,
illicit, liberating experiences that aloneness potentially can offer.
Because of the total privacy involved in living alone, one has free-
dom to do as one pleases. The freedom exists on many levels. Since you
are the only one physically and psychologically present, there are none
of the usual explicit or implicit boundaries, constraints, and distractions
inherent in living with another. You have the opportunity to be as
bizarre and outrageous as you choose, for example, eat, wear, do what-
ever you want; listen to the kind of music you like; sing; dance; and so
forth. You can push your experience to the limits. You have total flexibil-
ity and spontaneity in terms of the time and content of your activities.
You have sufficient time and psychological space to engage in reflection,
introspection, fantasy, and creativity.
This pursuit and development of your own values, beliefs, talents,
interests, and pleasures provides you with the rare opportunity to dis-
cover and construct who you are independent of the desires, expecta-
tions, and demands of others. This is one of the most powerful aspects
of self-development to be gained by living alone. No compromise is
necessary. Inherent in this process you reduce your need and depen-
dence on other people for meaning, involvement, and stimulation.
The goal is to shift one's attention from the fact that one is alone and
"deprived" of someone to share activities with to the activity itself and
one's enjoyment of it. When such shifts are made successfully, there can
be a level of intensity and involvement in whatever one is doing that
would be very difficult, if not impossible, to achieve with another per-
son present.
The point is emphasized that relationships with others come and go
for a variety of reasons: emotional, geographical, and so forth. Howev-
er, your relationship with yourself remains constant and ongoing,
whether you are in or out of a love relationship. A good relationship
with yourself consistently can provide you with a unique sense of con-
tinuity, stability, familiarity, comfort, acceptance, and total intimacy, for
example, you know everything about yourself.
An added motivation that can be given for developing an interest-
ing life alone is to ask oneself, If I'm bored and unhappy with myself,
what do I have to offer anyone else? What would I like to be able to offer
others? How can I make a genuine commitment to someone else if I
haven't made one to myself?
The following list of possibilities is then distributed:
Being at Home With Yourself
• Give yourself a manicure.
• Take a long, warm bath (try turning the lights off in the bath-
room).
• Explore a particular subject in depth: history, art, rock music.
• Explore an old, undeveloped interest, or talent, for example, play-
ing a musical instrument.
• Use your hands: painting, matting pictures, antiquing or building
furniture, needlepoint, potting.
• Be creative: write, sing, dance, cook, photograph.
282 LAURA PRIMAKOFF
• Self-development: keep a journal, meditate, do reading related to

personal growth.
• Listen to particular kind of music that you really enjoy.
• Study language on records or study about a foreign culture.
• Have a party for yourself.
• Play solitary games.
• Physical activities: yoga, self-massage, exercise program.
• Plant a garden-food or flowers.
• Set aside an afternoon, evening, or weekend to be with yourself
and have a really good time.
• Indulge yourself: Act out a fantasy; put on make-up, a costume.
• Be bizarre: spend the day naked, eat chocolate ice cream all day.
• Just remember, no one is there to say or even to think "You are so
Weird!"
Homework
The first homework assignment for this session involves recording
thoughts, behavior, and feelings when home alone in the aloneness
journal. Group members are asked to rate on a scale of 0 to 10 the quality
of their time home alone in terms of both interest and pleasure. The
second assignment involves setting aside some time during the week to
do something at home alone that one has never done before. The third
assignment involves working on one of the cognitive or behavioral goals
that each member set for him or herself at the beginning of the program.
SESSION 6: GOING OUT WITH YOURSELF
As in the previous session, smaller groups are formed for discus-

sion of the following questions:
1. Describe what would be a fantastic time for you with a friend or
lover (day or evening).
2. What kinds of things do you do with friends or dates?
3. What kinds of things do you go out and do alone now?
4. What kinds of things would you like to be able to do alone that
you aren't?
5. What prevents you from doing these things?
Within the context of members' answers to the last two questions,
the following summary is presented regarding the kinds of dysfunc-
tional attitudes that discourage people from going out alone: (1) fears of
other people seeing you and viewing you as lonely and rejected because
you are alone, (2) fears of being rejected at social events such as parties
or dances, (3) fears of being disappointed by not meeting a romantic
possibility at such an event, (4) fears of feeling lonely and of putting
yourself down for being lonely and alone, (5) women's fears of being
harassed or attacked by men, (6) passive, unrealistic attitudes that some-
one will call you and, therefore, you do not iniate social plans.
At this point, the following kinds of questions and strategies are
posed in order to challenge the validity of the previously identified
maladaptive thinking:
1. Are other people really looking? Even if they are, and have a
negative view of you, does that have to influence how you feel
about yourself? What other people think can have no direct im-
pact on you. Remember that many of them are not enjoying who
they are with, or wish they were single like you. Notice other
people who are alone.
2. Will you survive rejection and disappointment? Is it not worth
the risk?
3. Can you "stand" feeling lonely? What are you telling yourself
that is making you feel lonely and down on yourself?
4. Women can learn to be more assertive with men who hassle
them.
The remainder of the session is a discussion of the advantages and
positive attitudes involved in choosing to go out with yourself. Virtually
all of the advantages involved in spending time ·at home with yourself
apply, with the added dimension of being out in the world and poten-
tially interacting with others.
When going out alone one has tremendous freedom and flexibility.
You can be totally spontaneous; you do not have to make plans ahead of
time or coordinate logistics with another person. You are in control of
where and when you want to go, as well as when to leave. On the one
hand, you are not accountable to anyone at home, and on the other, you
do not have to compromise with anyone that you are with.
Being able to go out alone is inherently liberating in that you are not
allowing yourself to be controlled by your own or other people's nega-
tive attitudes about being alone, or by others' problematic behavior, for
example, potential rejection or harassment.
If you are able to become absorbed in the situation and the activity
itself, rather than in the fact that you are alone, other people's views of
your being alone, or your having to meet a romantic possibility, it be-
comes possible to have experiences approximating the excitement and
intensity of traveling alone.
284 LAURA PRIMAKOFF
When traveling alone, one is less constrained by the usual implicit

or explicit personal or cultural frames of reference and so is freer to think
and act in ways that one might not ordinarily. One is more likely under
such circumstances to have direct encounters with people, since an inti-
mate other is not present to serve as a buffer between oneself and
external events. In addition, in the absence of conversational demands,
one has a greater opportunity to observe, reflect on, and fantasize with
regard to the ongoing stream of experience that one is having.
To the extent that one acquires a history of interesting and meaning-
ful experiences with oneself, one is more likely to continue to seek out
and to value such experiences in their own right. The realization that on
any given night you can go anywhere and do anything alone and enjoy
it, with the added excitement of the possibility of meeting someone new
while you are doing it, serves to reduce your dependence on others for
going out. Taking yourself out can be experienced as an opportunity to
cultivate and practice an adventurous, risk-taking style. You then can
begin to view it as your choice, as your first choice, not second best. You
are making a commitment to spend an evening with yourself. The usual
assumption is that of course you would prefer to be with someone else
and could not find anyone (always forgetting that that someone else
could be boring and/or unpleasant), and that is why you are alone,
rather than the alternative possibility that you deliberately might have
chosen and preferred your own company.
The following suggestion list is then distributed:
Taking Yourself Out
Basic Premise: Almost anything you can do with another person you
can do alone; alone, you have the added possibility of meeting a new
person.
• Drive in the country (car or public transportation)
• Local sightseeing
• Festivals, fairs
• Take a walk
• Have a picnic
• Do something outdoors, for example, hiking, swimming, camp-
ing
• Museum
• Zoo
• Singles' bars, discos
• Folk dancing
• Shopping
• Parties, dances
• Pursue an interest, develop a skill on your own, or take classes in

gardening, photography, or another area
• Eat out
• Plays, concerts, movies
• Sporting events
• Participate in sports: bicycling, jogging, kite flying, ice skating
• Long distance traveling to wherever; for a day, a week, a month, a
year
• Plan a whole day or weekend for yourself of special things to do
and places to go
• Live out a fantasy with yourself: check into a fancy hotel; go to
gourmet restaurants; or, a less expensive fantasy, spend all day at
the movies
Homework
The first homework assignment for this session involves recording
thoughts, behavior, and feelings when out alone in public in the alone-
ness journal. The purpose is to identify: What do you think other people
are thinking about your being alone? What are you telling yourself that
is making you feel lonely, embarrassed, and so forth?
The second assignment involves your spending some time taking
yourself out and doing something that you ordinarily would not do
alone. You might reward yourself by telling someone about it, or you
might practice not telling anyone in order to keep the experience pri-
vate.
Participants are particularly encouraged to risk going to places
where they ordinarily would be ashamed or embarrassed to be seen, for
example, places where couples or at least two people go together. Exam-
ples would be, going to a restaurant where there is a chance that they
will be seen alone by people that they know, or going to a Friday night
movie by themselves.
SESSION 7: RELATIONSHIPS WITH OTHERS
The following suggestion list is distributed in order to stimulate

discussion:
Ways of Meeting Friends and Acquaintances:
1. Entertain, have parties
2. Join any group, course, or organization in which you are inter-
ested
286 LAURA PRIMAKOFF
30 Start your own group, if one doesn't exist

40 Take a temporary, interesting job that puts you in contact with a
lot of interesting people
50 Jobs in general
Ways of Initiating Potential Romance:

1. All of above methods, plus
20 Singles' bars and singles' clubs
30 Parties and dances
40 Tell friends that you're looking for people to go out with
5o Newspaper ads
60 Computer and dating services
70 The fine art of "the pickup"
Ways of Making Physical Contact:

10 Activities such as folk dancing, team sports
20 Set up massage group or reciprocal massage with friend
30 Spend time with children
40 Be physically affectionate with same-sex and other-sex friends
5o Sex
Additional Ways of Obtaining Intimacy and Emotional Support:

1. Co-counseling-get together with friend once a week and do
mutual therapy
20 Women's, men's or mixed support group
30 Therapy-individual or group
Miscellaneous Ways of Having Contact with People:

1. Spend time in public at events where there are people present
20 Be part of a recreational, political, professional, or spiritual orga-
nization that interests you
3o Maintain contact with people who live in other places by writing,
calling, and visiting
40 Travel-locally or further away
5o Do volunteer work, tutor, babysit 0 o
0
60 Get to know neighbors

70 Keep in touch with family
For more ideas, see: Sex and the Liberated Man (Ellis, 1976), The
Intelligent Woman's Guide to Dating and Mating (Ellis, 1979), and
First Person Singular (Johnson, 1977)
The following general principles for building a social network are

suggested:
1. One should be active in establishing a social life for oneself in
any and all ways that one can, for example, creating one's own
groups and initiating contacts with people in many different
circumstances.
2. One should be persistent in creating a social life, both in terms of
repeatedly initiating with people who are not as responsive as
one would like and in continuing to seek out new people with
whom one wants relationships.
3. One can get involved in the process of meeting people rather than
being overfocused on the outcome, for example, whether or not
the other person likes you, whether or not the relationship will
be romantic and sexual. One can begin to view meeting people
as a game, as fun, as experimental and adventurous. If you per-
sist enough you become desensitized to the fear and "shame" of
rejection and begin to realize that in fact you have nothing to lose
and everything to gain by extending yourself to others.
4. Friendship and a wide variety of social contacts is crucial to en-
joying single life and is a unique opportunity when one is single.
Friendship
In First Person Singular Stephen Johnson points out a number of
dysfunctional assumptions that may interfere with single people form-
ing satisfying friendships:
1. Lovers are better than friends. This belief results in putting much
more time and energy into the pursuit and maintenance of ro-
mantic relationships than into friendships.
2. Friendships should just happen. "People should be beating down
my door." This is a corollary of "lovers are better than friends."
It involves the idea that one does not have to pursue or work on
friendships in the same way as one does romantic relationships.
3. Deliberately and openly looking for companionship is shameful
and embarrassing, that is, "This proves that I'm a loser."
4. There are a number of rigid and excessive expectations that one
can have about friends:
a) Single people should have friendships only with others who
are single.
288 LAURA PRIMAKOFF
b) Good friends should be of the same sex.

c) "Best" friends are the only worthwhile friends.
d) Friends should always be there for you.
At this point, some basic concepts regarding the value of friendship

when one is single are presented. When single, friends can become
one's "family" and personal community. They sometimes provide as
much or more emotional and practical support as mates or family mem-
bers would. When single, it is important to have some single friends
because they will be more likely to have as much investment and com-
mitment to the relationship as you do. In addition, they can encourage
and accompany you in looking for romance and can serve as powerful
role models. Friendships generally tend to be more stable and enduring
than dating relationships.
There are a number of unique opportunities and advantages in
establishing friendships when one is single. You have the time, energy,
and freedom to devote to high quality intimacy with friends as well as to
a whole variety of types of friends. In fact, in terms of amount and
quality of intimacy, one has the potential of being less lonely in certain
respects than those who are isolated in couples.
One can have friendships with single and married individuals, cou-
ples, families with children, same-sex and other-sex individuals, people
of all ages, interests, and walks of life. As with engaging in activities
alone in general, one does not have a mate influencing or restricting
one's choices either explicitly or implicitly.
One type of friendship from which one can derive particular bene-
fits when single is platonic friendship with members of the opposite sex.
Such relationships provide the freedom to act in ways other than tradi-
tional sex-role dating behavior. One has the opportunity to experiment
with different and more satisfying behaviors with the opposite sex; to
become aware of and experience the potential friendship aspects of ro-
mance. At the same time, there usually is some degree of flirtation and
sexuality in cross-sex relationships. Thus, another purpose served is to
receive sexual and emotional confirmation from a member of the op-
posite sex. This helps to defuse the "desperate" search for romance.
Opposite-sex friends also can provide information as to the other sex's
point of view and experiences, as well as serve the practical function of
being an escort to various social events, if needed.
Inherent in having social relationships with a variety of different
people is the experience of having others react to one's personality both
positively and negatively. This multiplicity of reactions and feedback
from others can be very liberating; it becomes increasingly difficult to
attribute all negative reactions from others as being due to something
wrong with you in the face of constant contradictory evidence that there
are other people who seem to like and enjoy you.
Romance
With regard to romance, there are several myths that interfere with
seeking out potential romantic others. First, there is the notion that
finding a lover should happen spontaneously and that one should not
have to work to find a desirable woman or man. Second, even if indi-
viduals acknowledge that there is a need to look actively for partners,
they often regard legitimate ways of meeting the opposite sex as cheap,
superficial, or degrading, for example, singles' bars, newspaper ads,
and so forth. Attitudes such as 'Nice women don't approach strange
men" or "What would my (mother, friends, ex-lover) think if they knew
I was doing this?" prevent people from seeking out romantic relation-
ships. Additional inhibitory factors involve women's fears of being
hassled by men and both sexes' fears of being rejected.
Several concepts regarding seeking out romance are presented.
Group members are asked to consider the importance and value that
they place on a romantic love relationship in comparison with other
central aspects of their lives, for example, job, place of residence, and so
forth. People usually acknowledge that such relationships are of at least
equal if not greater importance to them than any other aspect of their
lives. They then are encouraged to ask themselves why it is that they
would systematically, persistently, and openly look for a job or a place
to live and not for a lover. An alternate conceptualization is offered,
namely, viewing finding a relationship as an important second job in
that it is a high priority goal in one's life. One then needs to employ
whatever systematic, time and energy-saving techniques are required in
order to attain this goal. These include any and all methods such as
singles' bars, ads, parties, and initiating contact with strangers.
Ellis (1979) and Johnson (1977) eloquently describe the advantages
in being able to encounter strangers who appear potentially desirable. It
is clearly the quickest and most efficient (time, energy, and in terms of
numbers) method for meeting members of the opposite sex. One can do
it any time and anywhere, opening up an ever present possibility of
meeting someone. This ability can help tremendously in reducing feel-
ings of desperation and hopelessness about romance. Such encounters
really provide one with the opportunity to focus on what each person
has to offer rather than on finding the "one and only," and to view such
experiences as learning and practice, and valuable in their own right,
regardless of the outcome.
290 LAURA PRIMAKOFF
If time permits, at this point in the session, the group can break into
pairs and practice initiating conversations, being rejected by others, and
being assertive by saying, "No," if not interested.
A final perspective is suggested with regard to developing satisfy-
ing relationships when one is single, involving an objective analysis of
what social relationships in fact provide.
The first category of experiences involves what others have to offer
us. They offer us themselves as people, as well as any skills and interests
that they may possess. In addition, many elicit certain ways of being in
us, and in that sense they "offer" us particular experiences of ourselves,
such as being witty, sexy, and so forth. Often we believe that we need a
particular other person in order to express or experience a particular
aspect of ourselves.
When single, one has the potential of multiple people to choose
from both in terms of getting to know them and in getting to express
different parts of oneself. The additional possibility that one has is to
develop some skills, interests, and modes of self-expression for oneself.
A second category of experiences involves your experience of being
loving and giving. Thus, rather than focusing on what you get or need
from others, you can focus on what you have to offer and give to them.
This involves shifting from a needy, deficit, powerless stance to an
active, loving, giving one. You are in fact offering the other person both
an opportunity to experience you and particular experiences of them-
selves that you can elicit.
When the focus of interpersonal gratification begins to shift to
oneself in terms of one's capacity to love and one's experience of being
loving, one realizes that there are many potential people who can receive
one's love and giving. Other people then can be experienced as provid-
ing the opportunity for you to give and to love.
In summary, when single, one has the time, energy, and freedom to
push one's interpersonal experience to its limits, for example, to engage
in different types of relationships with a variety of different types of
people, such as, simultaneous romances; to be experimental and live out
one's fantasies in terms of certain kinds of people and/or activities.
Thus, in this crucial area of one's life, one again has the luxury of
exploring, indulging, and developing one's own tastes, desires, and
rhythms, both emotionally and sexually.
Homework
The first homework assignment for this session involves doing an
analysis of one's current friendship and romantic situations and their
future possibilities in terms of quantity and quality. (See Johnson's First

Person Singular, 1977, pp. 149-155, for details of analysis.) A second
assignment is to initiate some new action with a friend or stranger, for
example, hug a friend or practice starting a conversation with an other-
sex stranger. A third possible assignment is to attempt to correct dys-
functional thinking about initiating contact with others, for example, "I
couldn't stand it if she wasn't interested in going out with me." "He'll
think I'm desperate if I just start talking to him out of the blue."
Group members are given Skills for Friendship and Romance (see be-
low) to help them better identify what deficits they may have, so as to
design appropriate homework assignments for themselves.
In addition, group members are asked to bring some of their favor-
ite food to the next session, but are informed that the leaders also will
have food available for them.
Skills for Friendship and Romance

1. Social attributes and skills for friendship maintenance
• Making and keeping same-sex friends
• Making and keeping other-sex friends
• Developing depth of friendships
• Ability to communicate with friends
• Being with friends regularly
• Initiating outside activities with friends
• Entertaining friends at home
• Finding ways to meet new friends
2. Social attributes and skills for dating, sex, and amative relationships
• Initiating conversation with other sex
• Finding ways to meet other sex
• Ability to attract members of other sex
• Ease in asking for dates
• Ease in refusing dates
• Dating regularly or often
• Knowledge of and comfort with dating etiquette
• Ease in communicating with other sex in early contacts or dating
• General ease in dating
• Ease in being affectionate
• Ease in receiving and reciprocating affection
• Ease in rejecting affection
• Ease in making sexual advances
• Ease in receiving and reciprocating sexual advances
• Ease in rejecting sexual advances
• General sexual ability
• Ease in sexual interaction
• Ability to communicate about affectional and sexual behavior
• Ability to communicate in love-sex relationships
• Quality of love-sex relationships
(Johnson, 1977, pp. 80-81)
292 LAURA PRIMAKOFF
SESSION 8: OPEN SESSION
This session is designed to give group members an opportunity to

discuss issues that are not included in the program or to further discuss
issues that have been raised in the program.
The following kinds of topics have been suggested by group mem-
bers:
1. Social pressure from peers and family to enter into a romantic
relationship and get married and not remain single.
2. All aspects of intimate, romantic relationships, for example, ini-
tiating them, sexuality, ways to maintain one's individuality and
identity.
3. How to become more personally, aesthetically, or intellectually
creative when living alone.
4. How to develop a resource network for various kinds of practical
and personal help.
The homework assignment for this session involves working on one
of the cognitive or behavioral goals that each member set for him or
herself at the beginning of the program. An alternate assignment is for
the individual to work on one of the areas that has been raised during
the course of the group that he or she would like to pursue further.
SESSION 9: DEVELOPING A PHYSICAL, SENSUAL RELATIONSHIP

WITH YOURSELF
This session begins with a relaxation exercise that facilitates group

members feeling more comfortable with the subsequent experiential
exercises.
This session focuses on one's ability to have direct encounters with
the external, physical world, as well as to provide pleasure to oneself
through tuning into and focusing on one's own ongoing bodily experi-
ences. The appreciation of one's daily physical experience provides a
type of direct confirmation that one is alive and exists, which sometimes
can be weakened when living alone and out of physical touch with
others.
Downing's ideas in The Massage Book (1972) form the basis of the
discussion of body self-awareness. He states,
Our body, its possibilities of movements, and its relation to gravity and the
earth are the background from which everything else must emerge. To come
to terms with this on a real emotional level is perhaps the most important
kind of self-encounter a person can have. (p. 134)
Downing points out that the sense of touch is as crucial a contact

with reality as the sense of sight. However, in our culture the sense of
sight dominates. In order to tune into one's tactile experience, one can
become aware of one's body during the day. One can focus on such
sensations as weight, texture, and pressure, when picking up or han-
dling objects or when making contact with the external environment,
such as sitting in a chair or walking. The notion of one's body as a field
of energy is introduced and the point is made that the goal of becoming
more aware of the body is to experience directly one's internal energy.
Self-massage
In The Massage Book, Downing has a section on self-massage. He
suggests that one can do self-massage when one is feeling tired and
numb, in order to "wake up" one's body. Learning to touch and nurture
one's body in this way is a good beginning at accepting and loving it. At
this point, the group does some yoga and stretching exercises in order to
loosen up physically so as to do some self-massage. The leaders then
demonstrate and instruct the group in a series of self-massage exercises.
(See The Massage Book, pp. 122-125 for details.) The goal is to experiment
and explore as much as possible different areas of one's body and differ-
ent methods of massage.
Group members are given the self-massage instructions so as to be
able to continue practicing at home if so desired.
Sensory Awareness of Eating

The next exercise helps group members to focus on their physical
gratification in the present moment in their daily lives, by heightening
their awareness of the sensual, pleasurable aspects of eating. The exer-
cise is excerpted from the Weight Control Treatment Manual (Hawkins,
Setty, & Baldwin, 1977).
Each group member eats a small portion of .his or her favorite food
that they have brought to the session or the leaders can provide food.
The following instructions are then given:
First notice the sight of the food as you slowly raise it toward your mouth.
Hold it in front of your mouth and take in its smells. Notice how good it
294 LAURA PRIMAKOFF
smells as you slowly, slowly touch it to your lips ... be aware of the sensa-
tion of the food touching your lips ... now touch it to the tip of your tongue
and notice the food's texture ... let it touch the rest of your tongue, noticing
texture and smell and now ... bite down slowly, slowly on the food and
chew it slowly ... continue slowly chewing being fully aware of the taste,
smell, temperature, and texture of the food ... enjoy the pleasure of the
chewing . . . now swallow slowly and experience the pleasurable aftertaste
and concentrate on it for a moment as you put your utensils down ... just
enjoy the food's aftertaste.
Now take the second bite in the same manner as the first. Enhance the
sensory pleasures as before, but this time as you swallow suggest to yourself
that the taste is still pleasant but now you're beginning to become aware of a
slight increase in comfort, fullness, and satisfaction. Pause to enjoy these
feelings.
With your third bite, continue to enjoy the pleasure of eating as feelings
of fullness, comfort, satisfaction, and relaxation grow stronger. Pause again
to enjoy these feelings.
As you continue to slowly eat and enjoy, your feelings of fullness, corn-
fort, and satisfaction will become complete. Continue eating until you finish
the food you've chosen to eat, or stop earlier when you feel satisfied. (pp.
52-53)
Masturbation
At this point, both in terms of its being the ninth session of the
program, and having done relaxation and self-massage in this session, I
have found it fairly easy to straightforwardly raise the issue of masturba-
tion when living alone.
Dodson's manifesto on masturbation, Liberating Masturbation: A
Meditation in Self-Love, (1974) and some ideas presented in The Challenge
of Being Single (Edwards & Hoover, 1974) form the basis of the discus-
sion. Several myths about masturbation are presented. First, there is the
notion that only teenagers, lonely people, and masturbators do it. Mas-
turbation has strong, negative connotations of childishness, perversion,
and loneliness. Second, there is the belief that if you masturbate at all,
and certainly if you do it too often, there is something wrong with you
and your sex life. It is generally considered to be a second-rate sexual
activity.
The facts, however, are contrary to these notions. Humans mastur-
bate throughout their life cycle; married people masturbate regularly. It
would seem more accurate to view masturbation as another form of sexu-
al activity, rather than as an inferior one. It is analogous to people
having a need for time alone when involved in a marital relationship.
The most important fact within the living alone context is that mas-
turbation is the major consistent, dependable sexual outlet for unmar-
ried adults. In fact, it can be as satisfying, or more so, both physically
and emotionally, than sexual contact with someone else. It depends on
how one chooses to view it. There are several distinct advantages that
masturbation has over sex with another. It is always available. There are
none of the performance, social, pregnancy, or venereal disease anx-
ieties associated with sexual contact. One generally is guaranteed of
attaining orgasm. One can gain sexual knowledge of oneself, practice
being uninhibited, and engage in unlimited erotic fantasy. These latter
experiences have the potential to be as arousing and exciting, or more
so, than an actual sexual encounter.
Dodson describes how many individuals have self-loathing and
shame about their bodies, appearance, and natural functions. Loving
masturbation can help to counteract some of these self-destructive atti-
tudes. Dodson takes a fairly radical position in stating that masturbation
is our "primary sex life"; our first natural sexual activity and the way we
originally discover our eroticism and learn to love ourselves. Everything
beyond that is simply how we choose to "socialize" our sex life. Concep-
tually, this is a useful notion in that it provides a powerful metaphor for
the primacy of achieving self-love when living alone and then extending
one's love to others. Alternate terms such as self-pleasure or sex with
yourself may better express the spirit of masturbation within this context.
On a practical level, the basic principle suggested for high-quality
masturbation is to create an erotic environment in the same way as one
would for a sexual experience with another; books and stores specializ-
ing in auto-erotica are mentioned.
A greater ability to truly appreciate and provide oneself with phys-
ically pleasurable and sensual experiences in one's daily life helps one to
keep a more reasonable perspective with regard to sexual relations with
others. Sexual contacts with others are extremely pleasurable physical
experiences, but not the only ones, and not always the preferred ones.
The following suggestion list is then distributed:
Developing a Physical and Sensual Relationship with Yourself
• Relaxation exercises
• Meditation
• Yoga
• Various body awareness techniques
• Self-massage
• Burn incense
• Sports: bicycling, swimming, jogging
296 LAURA PRIMAKOFF
• Lying in sun
• Long, warm baths and showers, using your favorite lotions,
soaps, and perfumes
• Listening to your favorite music
• Having a touchable pet
• Dancing at home
• Mirrors (looking at yourself doing whatever)
• Wearing clothes and having home furnishings that are pleasur-
able to touch and beautiful to look at
• Auto-eroticism: candles, colors you like in your home, "sex toys"
• Working with your hands to make things; building furniture, bak-
ing bread
• Pottery
• Painting
• Sculpting
• Spending time in nature-walking, hiking, swimming . . .
• Flowers
• Cooking good food
• Playing your own music-piano, guitar, singing
Homework
The first homework assignment for this session involves doing
something physical or sensual with oneself that one has never done
before, or changing the environment in some physically pleasurable
way. The second assignment is to try to anticipate any reactions one
might have to the termination of the group the following week and to
attempt to generate cognitive and behavioral strategies for continuing
work on unresolved problems in living alone.
SESSION 10: UNIQUE ADVANTAGES AND OPPORTUNITIES OF

SINGLE LIFE-STYLE
This session is a discussion of the longer-term advantages and op-

portunities of living alone and being single. When single, one can grow
and change at an accelerated rate because of the freedom, variety, and
unpredictability of one's experience. Being single affords one the oppor-
tunity to channel the type of emotional energy that ordinarily would be
directed toward a lover, spouse, and family into self-nurturance, various
forms of artistic or intellectual creativity, or commitment to larger voca-

tional or social causes.
The lack of obligations to a spouse and/or children results in certain
types of freedom. One has financial independence and freedom; one can
spend one's money on oneself and as one chooses. One can have a great
deal of geographical mobility in terms of working, living, and traveling
where one wants. These kinds of freedom provide the possibility of
more adventure, novelty, and excitement, both in one's daily life and in
a longer time frame, for example, spending a year living in a foreign
country.
One can have social relationships of all kinds and experience differ-
ent roles and ways of being while in them. One is free to make a primary
commitment to different types of people, for example, a sibling or a
close friend, or to a larger group of people, such as, friends or a commu-
nal group. One can participate in "alternate" life-styles such as commu-
nal living or living with a platonic other-sex friend. Living outside the
structure of marriage opens up the possibility of questioning the tradi-
tional nuclear family, sex roles, and so forth. One can develop more
personal and original life goals, perspectives, and values, without hav-
ing to accommodate or compromise because of a marital relationship.
One is freer to engage in more playful, creative, and imaginative ways of
living, involving greater degrees of experimentation and risk taking.
Because of the greater availability of time and emotional energy
when single, there is an increased potential to make substantial commit-
ment to social causes involving large groups of people or communities.
The fact that a greater possibility exists of being committed to people
and goals outside of oneself when single is directly counter to the derog-
atory stereotypes of "selfishness" and "self-indulgent narcissism" that
often are associated with choosing to live alone or be single. The reality
is that single individuals have the necessary resources, in terms of time
and energy, to devote to many people and the larger community, rather
than being more restricted to the confines of the nuclear family.
A fundamental shift that can begin to occur for individuals who are
committed to living alone and are successful at doing so is from content-
oriented experiencing to process-oriented experiencing. When living
alone for substantial lengths of time, one may develop a heightened
awareness of the relativity, multiplicity, and changeability of the exter-
nal circumstances of one's life. One's external reality shifts in terms of
people, places, and activities. It becomes apparent that it is oneself who
is constant in the face of such external changes and who gives the
meaning, structure, and continuity to the events and experiences of
one's life.
298 LAURA PRIMAKOFF
As a result of such realizations, one becomes more psychologically

self-sufficient, as well as focused on one's internal experience and self-
development; one's attachments, commitments, and values may change
accordingly. Instead of the traditional commitment to long-term, exclu-
sive, conjugal intimacy, or to any other particular external content, for
example, financial or career achievement, commitments to modes or
qualities of experience involving certain aesthetic, ethical, or spiritual
dimensions, regardless of the specific content per se, may begin to take
precedence. Such a shift in both the content and structure of an indi-
vidual's consciousness may involve the ability to achieve transcendent
states of consciousness in which there is a heightened sense of merging
self with the external world of humankind and nature as a whole.
TERMINATION
A general approach to living alone that transcends the particular

content areas per se, has been suggested in the program. The approach
consists of: (1) making a commitment to a relationship and a life with
oneself analogous to a commitment to a love relationship, (2) seeking
out the unique opportunities and life experiences that only living alone
has to offer, and (3) identifying the actual emotional and practical depri-
vations and deficits involved in living alone and systematically attempt-
ing to substitute or replace them.
It is emphasized that obviously 10 weeks is not sufficient time to
relearn basic ways of living alone. An attempt is made to give group
members a realistic anticipation of difficulties that they may encounter
as they continue to live alone. The suggestion is made that one's rela-
tionship with oneself goes through the same kinds of fluctuations and
phases as an intimate relationship with another; such cycles being a
function of the relationship itself, as well as a multitude of life events
and circumstances. It is during the problematic phases that members are
encouraged to implement self-care, self-management, and problem-
solving techniques. These involve first doing a careful assessment of
precisely what the problem is and then either learning to solve it oneself
or finding the necessary resources to do so.
The following specific suggestions for following through on the
program are made: (1) For emotional support, one can set up a "co-
counseling" arrangement with someone, getting together an hour each
week to express feelings and exchange suggestions, support, and ad-
vice. Another possibility is to form one's own singles' support group.
(2) For cognitive support, one can continue to respond in writing and
behavior to one's own dysfunctional thinking. One can make audio

tapes of oneself talking more reasonably and play these when alone to
remind oneself of people who do care, the advantages in being alone,
the disadvantages of being in a love relationship, and so forth. One can
continue to do reading that reinforces the ideas discussed in the group.
Two books that are highly recommended for this purpose are: Single
Blessedness (Adams, 1976) and The Challenge of Being Single (Edwards &
Hoover, 1974), as well as several biographical books, Gift from the Sea
(Lindbergh, 1955), Journal of a Solitude (Sarton, 1973), and Walden and
Other Writings (Thoreau, 1937) that provide affirming and inspiring role
Lastly, group members are encouraged to continue to structure
weekly goals into their lives either on their own or through the help of a
singles' support group, employing any and all methods, such as specific
homework assignments, rewards for themselves, and so forth. Group
members often exchange phone numbers so as to continue either indi-
vidual or group contact.
There are several goals that the program strives to achieve. A prima-
ry one is to offer a vision and a taste of a discovery and self-construction
process in which one has the unique luxury of engaging when living
alone and single. Strengthening group participants' ability to spend
pleasurable, involving time, alone and with a variety of others, helps
them to reduce their need for a romantic relationship. Paradoxically, in
fact, such a discovery/construction process of who one is and what one
wants and values is likely to enhance one's ability to seek out, obtain,
and maintain a long-term intimate relationship, if one is desired. Re-
gardless of one's long-term goals, however, the objectives of the pro-
gram are to improve the quality of one's ongoing experience alone so
that the single life-style, for whatever duration, becomes an enjoyable
and meaningful way to live.
REFERENCES
Adams, M. Single blessedness. New York: Basic Books, 1976.

Altman, I. The environment and social behavior. Monterey, Calif.: Brooks/Cole, 1975.
Beck, A. T. Thinking and depression. New York: The Institute for Rational Living, undated.
(Reprinted from Archives of General Psychiatry, 1963, 9, 324-333. Copies available from
the Institute for Rational Living, Inc., 45 East 65th St., New York, N.Y., 10021.)
sities Press, 1976.
Beck, A. T., & Greenberg, R. L. Coping with depression. New York: The Institute for Rational
Living, 1974. (Copies available from the Institute for Rational Living, Inc., 45 East 65th
St., New York, N.Y., 10021.)
Guilford, 1979.
300 LAURA PRIMAKOFF
Bracken, P. The I hate to housekeep book. New York: Fawcett, 1962.

Brownfield, C. A. The brain benders. New York: Exposition, 1972.
Burns, D. Feeling good. New York: Morrow, 1980.
Creel, H. L. Cooking for one is fun. New York: Quadrangle, 1976.
Deaton, J. E., Berg, S. W., Richlin, M., & Litrownik, A. J. Coping activities in solitary
confinement of U.S. Navy POW's in Vietnam. Journal of Applied Social Psychology, 1977,
7, 239-257.
Dodson, B. Liberating masturbation: A meditation of self-love. New York: Author, 1974.
Downing, G. The massage book. New York: Random House, 1972.
Edwards, M., & Hoover, E. The challenge of being single. New York: New American Library,
1974.
Ellis, A. Sex and the liberated man. Secaucus, N.J.: Lyle Stuart, 1976.
Ellis, A. The intelligent woman's guide to dating and mating. Secaucus, N.J.: Lyle Stuart, 1979.
Ellis, A., & Harper, R. A. A new guide to rational living. Hollywood, Calif.: Wilshire, 1975.
Going it alone: The new status of singleness. Newsweek, September 4, 1978.
Hawkins, R., Setty, R. & Baldwin, B. Weight control treatment manual. Unpublished manu-
script, University of Texas at Austin, 1977.
Ittelson, W. H., Proshansky, H. M., Rivlin, L. G., & Winkel, G. H. An introduction to
environmental psychology. New York: Holt, Rinehart & Winston, 1974.
Johnson, S. M. First person singular. New York: Signet, 1977.
Kangas, P. E. The single professional woman: A phenomenological study. Unpublished doctoral
dissertation, California School of Professional Psychology, 1977.
Kanter, M. K. Psychological implications of never-married women who live alone. Unpublished
doctoral dissertation, California School of Professional Psychology, 1977.
Kelly, K. L. Lifestyles of unmarried adults. Unpublished doctoral dissertation, The University
of Nebraska-Lincoln, 1977.
Kovacs, M. Cognitive therapy of depression: Maladaptive structures. Unpublished manuscript,
Center for Cognitive Therapy, Philadelphia, Pa.
Lazarus, A. A. Behavior therapy and beyond. New York: McGraw-Hill, 1971.
Lazarus, A. A. Multimodal behavior therapy. New York: Springer, 1976.
Lilly, J. C. The deep self. New York: Warner, 1977.
Lindbergh, A. M. Gift from the sea. New York: Random House, 1955.
Maslow, A. H. Toward a psychology of being. New York: D. VanNostrand, 1968.
May, R. Man's search for himself. New York: Norton, 1953.
Meichenbaum, D. Cognitive-behavior modification. New York: Plenum, 1977.
Naar, J., & Siple; M. Living in one room. St. Paul, Minn.: Vintage, 1976.
Parmalee, P., & Werner, C. Lonely losers: Stereotypes of single dwellers. Personality and
Social Psychology Bulletin, 1978, 4, 292-295.
Peele, S. Love and addiction. New York: Signet, 1976.
Perlman, D., & Peplau, L. A. Toward a social psychology of loneliness. In R. Gilmour & S.
Duck (Eds.),/ Personal relationships in disorder. London: Academic Press, 1981.
Primakoff, L. Patterns of living alone and loneliness: A cognitive-behavioral analysis. Un-
published doctoral dissertation, University of Texas at Austin, 1981.
The Reader's Digest complete do-it-yourself manual. New York: Norton, 1981.
Sarton, M. Journal of a solitude. New York: Norton, 1973.
Shaver, P., & Rubinstein, C. Living alone, loneliness and health. Paper presented at the
annual convention of the American Psychological Association, New York, September
1979.
Stein, P. J. Single. Englewood Cliffs, N.J.: Prentice-Hall, 1976.
Suedfeld, P. Aloneness as a healing experience. In L. A. Peplau & D. Perlman (Eds.),

Loneliness: A sourcebook of current theory, research and therapy. New York: Wiley-Intersci-
ence, 1982.
Thoreau, H. D. Walden and other writings. Ed. by Brooks Atkinson. New York: Random
House, 1937.
Young, J. Loneliness, depression and cognitive therapy: Theory and application. In L. A.
Peplau & D. Perlman (Eds.), Loneliness: A sourcebook of current theory, research and
therapy. New York: Wiley-Interscience, 1982.
Zuckerman, M. Perceptual isolation as a stress situation. Archives of General Psychiatry,
1964, 11, 255-276.
13
The Apprenticeship Model
Training in Cognitive Therapy by
Participation
STIRLING MooREY AND DAVID D. BuRNS
INTRODUCTION AND HISTORY OF Co-THERAPY
Psychotherapy traditionally has been a meeting of two individuals;

whether the therapist has seen him or herself as counselor or analyst,
the assumption has been that the one-to-one relationship is an essential
factor in the solution of the patient's problems. In the relatively brief
history of psychotherapy, there have been those who have noted the
value of a therapeutic ratio greater than one-to-one, both as a treatment
and training method. In the 1920s Adler remarked on the usefulness of
bringing in another counselor when sessions with children became diffi-
cult and emotional blocking occurred. Reeve (1939) used a combination
of social worker and psychiatrist to teach the former interviewing skills
and found the "joint interview" surprisingly effective as both a thera-
peutic and a training device. It was only in the 1950s that "multiple
therapy" was explored in any systematic manner. Whitaker, Warkentin,
and Johnson (1950) found it more effective than individual therapy with
virtually all patients. They felt that this approach required therapists of
"equal capacity" and therapeutic experience. Dreikurs (1950) in contrast
claimed that multiple therapy could be used with therapists in training.
His description of the techniques and dynamics involved in this type of
theory contains the clearest and most practical advice of all the papers in
this field. Haigh and Kell (1950) also saw the potential of this method.
STIRLING MooREY • The Maudsley Hospital, Denmark Hill, London SES, England.
DAVID D. BuRNs • Department of Psychiatry, School of Medicine, University of Pennsyl-
vania, Philadelphia, Pennsylvania 19104.
303
304 STIRLING MOOREY AND DAVID D. BURNS
They emphasized that the student gains far more if he or she is a partici-
pant in the session than if the role is restricted to that of passive ob-
server, which is the more common form of teaching (Strauss, 1950). Lott
(1952) used "multiple therapy" as a means of training nonmedical psy-
chotherapists, while Adams (1958) described his use of a model where
supervisor and trainee worked directly and actively with the patient.
More recently, Rosenberg, Rubin, and Finizi (1968) recorded the
thoughts of supervisor and student on the experience of "partici-
pant-supervisor" in the teaching of psychotherapy. They found the
opportunity for direct observation of the trainee valuable and felt the
setting allowed the trainee to try out new kinds of interventions in a safe
atmosphere, as well as providing against the therapist getting on the
wrong track. Treppa (1971) and Watterson and Collinson (1974) have
provided reviews of the development of multiple therapy in all its
forms. These reports all have been from a broadly psychodynamic view-
point. Although there are scattered reports of participant training in
behavior therapy (e.g., Matefy, Solanch, & Humphrey, 1975) there is no
detailed discussion of this method; yet it is a method widely employed
in training behavior therapists. Similarly, there have been no accounts of
the use of co-therapy in a cognitive setting.
Before moving on to discuss our own experience of this method as a
training device it may be useful to clarify some of the nomenclature in
this area. An enormous number of names have been applied to the
three-way approach, including: co-therapy, multiple therapy, role-di-
vided therapy, three-cornered therapy, joint interview, cooperative psy-
chotherapy, and dual leadership. Multiple therapy seems to be the most
widely used, but is ambiguous. We prefer the term co-therapy, which is
short and clearly conveys the cooperative nature of the enterprise. In
addition, we see the process of learning by participating as a form of
learning by apprenticeship, and for this reason refer to the use of co-
therapy for training as the apprenticeship model.
THE APPRENTICESHIP MoDEL OF CoGNITIVE Co-THERAPY
The apprenticeship model was born in the summer of 1979 when

Beck suggested that the student therapist Moorey spend some time
sitting in on therapy sessions with the senior therapist, Burns. We both
found this an interesting and useful way of training. Our experience was
built up during two one-month stays when we worked together inten-
sively and developed some of the techniques described below.
THE APPRENTICESHIP MODEL 305
THE PRocEss oF CoGNITIVE Co-THERAPY
Our method of co-therapy evolved over a number of sessions as the

student therapist became more confident and capable of increasingly
sophisticated interventions. The co-therapy differed from individual
therapy on two major counts: the structure of the session and the type of
techniques used.
Structure of the Therapy Session

With any patient the preparation for this form of therapy begins
outside the therapy session. The patient is asked if he or she objects to
the apprentice sitting in on one or more sessions (only one patient
declined out of approximately 30 who were approached). A brief de-
scription is given of the student's qualifications, experience as a thera-
pist, and personality, and it is emphasized that the apprentice will par-
ticipate fully and equally in the session as a co-therapist. Surprisingly,
most patients find the prospect of another active therapist much less
threatening than the idea of a passive observer. Patients are reassured
that although it may seem awkward at first to have a stranger join the
session, the majority of patients have become quite comfortable with the
co-therapist's presence and have benefited from the additional feed-
back. It is further emphasized that if at any time during the first or
subsequent sessions the patient wishes the apprentice to leave this is
totally acceptable.
At the beginning of the first co-therapy session the therapist sum-
marizes the patient's history. This summary includes a brief personal
history, the current focus of therapy and the strengths and weaknesses
of the therapy so far. The patient is then asked if he or she feels the
summary was accurate.
The initial summary serves several important functions. The ap-
prentice gets an overview of the patient's difficulties and hears how an
experienced therapist has conceptualized the problem and devised
methods for change. Once the apprentice has been presented with the
weaknE'sses of the present approach he or she immediately can begin to
think of alternative strategies. Thus the slightly different outlook of the
apprentice immediately is brought to bear on the area where he or she
can be most useful.
The summary also provides a unique opportunity for the patient to
see how the therapist approaches the problem. The therapist can benefit
from the patient's feedback and further input. It is useful to provide

further summaries at the start of each interview, particularly if the ap-
prentice is not able to attend every session.
Example--Mr. Jones has been in treatment with numerous therapists for
over 25 years because of mild depression and severe tension and anxiety
which he experiences at work. In particular, he is plagued by headaches and
neck tension which persist all day, every day, and has had no relief despite
continuous psychotherapeutic efforts. He holds a top executive position in a
prominent corporation but feels intensely inadequate--he experiences him-
self as a "fraud"-in spite of an illustrious career.
We are currently focussing on his fear of disapproval. This causes him to
experience great apprehension in group discussions with peers. Although he
sees intellectually that this fear of disapproval is somewhat irrational, he
continues to believe emotionally that a catastrophe would occur if he tried to
offer some ideas of his own and appeared foolish in front of his associates.
Consequently, he feels inhibited and anxious and says very little during
group meetings. The therapy has been characterized by excellent rapport and
substantial learning, but Mr. Jones is disillusioned because his five months of
once weekly sessions have failed to produce any significant emotional
change or relief from neck tension. He is beginning to feel pessimistic about
the chances that cognitive therapy will work.
We have recently been using role playing to teach him how to talk back
to the negative thoughts that tend to upset him when he is in a group
meeting. He attacks me with negative thoughts and I model rational ways of
responding. Then we reverse roles so he can learn how to change his think-
ing. He finds this exciting, so much so that he has recently been playing
tapes of the sessions several times between sessions.
Mr. Jones then is asked to add his impressions. Following this the
agenda is set for the day's session and a therapeutic strategy is adopted
that allows the patient and the two therapists to work as a three-member
team. Specific techniques employed in cognitive cotherapy will be de-
scribed in the next section.
Toward the end of the session the therapist asks for specific nega-
tive and positive feedback regarding the presence of the apprentice.
Once these reactions have been noted the patient is asked if he or she
would like the apprentice to participate in further sessions. In our expe-
rience, patients usually responded with a strong affirmative. In such
cases it is crucial to spell out precisely when the apprentice will or will
not be present, because the unexpected absence of the apprentice at a
future session may be quite upsetting to the patient. For example, when
the apprentice was not present for the second session with a 45-year-old
depressed accountant, the patient burst into tears. His cognitions were:
"I wasn't interesting enough for Stirling (Moorey) to want to come back.
This shows what a dull person I really am." The patient reported he
believed these thoughts "over 99%." When the senior therapist pointed
THE AP,''RENTICESHIP MODEL 307
out that, in fact, Stirling was in Boston that day to meet his parents who
had flown in from London, the patient was able to see just how wide of
the mark his interpretation had been. Although this evolved into an
excellent learning experience for this patient, the potential for hurt feel-
ings can be minimized if the patient knows beforehand whether or not
the apprentice will be present.
THERAPEUTIC TECHNIQUES
All the interventions of the individual therapy sessions are, of

course, used in the three-way session (See Beck, Rush, Shaw, & Emery,
1979; Burns, 1980). At certain points one therapist will sit back while the
other pursues a certain line of inquiry, using techniques such as the
Socratic method, asking for evidence regarding certain irrational beliefs,
and so forth. At these moments the session is in effect a conventional
psychotherapeutic interview. There is always the danger of allowing the
three-way approach to become two two-way approaches and for this
reason it is best to combine the use of individual techniques with the use
of three-way techniques in as harmonious a way as possible.
From the apprentice's point of view these short two-way interac-
tions within the co-therapy session may be very valuable. When the
supervisor is talking to the patient the student has the opportunity to
watch an experienced therapist at close quarters. Audio- and videotapes
cannot capture the immediacy and involvement of this experience. The
apprentice watches the therapist tackling the same cognitive fallacies
that he or she at any moment may be called on to work with. In addition
to the proximity of a model, the trainee also has the opportunity to make
interventions. For the novice therapist these first interventions can be
set up very carefully by the supervisor. The three-way session provides
a nonthreatening environment in which the apprentice can try out the
techniques learned from books and seminars. If anything goes wrong
the supervisor always can sort out the problems. Haigh and Kell (1950)
have emphasized the value of this setting in giving the novice confi-
dence in his therapeutic ability.
Three-Way Techniques (See Table 1.)

1. Externalization of Voices. ln our experience this has proved one of
the most exciting and powerful therapeutic tools of co-therapy. It is an
extension of the written automatic thoughts/rational response technique
308 STIRLING MooREY AND DAviD D. BuRNs
used in cognitive therapy. Instead of writing down his or her automatic

thoughts the patient is encouraged to speak them out loud and the
therapist responds with a more adaptive statement. The patient can give
feedback on whether or not the response was meaningful. The situation
then is reversed, with the therapist verbalizing the negative thoughts
and the patient providing rational responses. This technique lends itself
very well to the three-way model because of the number of possible
dyadic interactions. These can be arranged in a hierarchy of difficulty
and potential threat to the patient.
Automatic thoughts Rational responses
Option 1 First therapist Second therapist
Option 2 Patient Either therapist
Option 3 Either therapist Patient
In the least threatening interaction (Option 1) the patient watches

while the two therapists play his or her internal dialogue. By listening
and observing he or she quickly is able to learn the method. In the most
threatening (Option 3), the patient has to provide rational responses to
his or her own very convincing negative thoughts which are verbalized
by the therapists. This is not only difficult but also arouses anxiety over
possible failure. As the role playing passes down the hierarchy from
Option 1 to Option 3 the patient gains confidence in answering his or
her automatic thoughts.
Here is an example of Option 2. The patient is again Mr. Jones. We
are dealing with his automatic thoughts about disapproval in social sit-
uations and his fears about role playing in particular.
JONES: (Playing the role of the Automatic thoughts): This kind of back and forth
conversation and discussion in small groups is what makes you get uptight so
you feel you don't even have a single thought in your mind.
STIRLING: (In the role of the Rational responses): It's not true that I don't have a
single thought in my mind because I can usually bring something out. The
more exposure that I have to a situation that brings about tension the more
likely I am to be able to cope with it.
JONES: (As Automatic thoughts): Well, that may be so but you know how embar-
rassed you get if you open your mouth and don't have a real classic gem of an
opinion to present. So therefore it's better to keep your mouth shut and be
quiet.
STIRLING: (As Rational responses): It seems safer to keep quiet but that is really a
distortion. Keeping quiet is going to increase my tension, increase my fear of
saying something. If I say something, anything at all, then I'm going to break
out of this cycle of tension. So the more times I can say something, even if it is
totally ridiculous, the more likely I am to solve this problem.
THE Al'l'RENTICESHIP MODEL 309
Now the roles are reversed with Stirling and Dave as the automatic
thoughts and Mr. Jones providing the rational responses, as in Option 3.
STIRLING: (In the role of the Automatic thoughts): If you say anything at all at one of
these meetings you're going to make a fool of yourself and that's going to be
the end of everything. You'll lose all the praise and esteem you've had from
your colleagues.
JONES: (In the role of the Rational responses): Well, I don't think there's any evi-
dence really to support that, because over the last 30 years I have performed in
a responsible way or I wouldn't be where I am, and I'm not going to lose that
overnight.
DA vm: (Also playing the role of the Automatic thoughts): Yeah, but if you've got a
beaker filled with clear water and we've been talking about one drop of black
ink, it can discolor the whole beaker.
JONES: (As Rational responses): Well, I think that's all-or-nothing thinking and I
don't think that one little drop of black ink is going to have much effect on the
color of the whole glass of water.
STIRLING: (As Automatic thoughts): It's going to change the way your peers think
of you. You better not take a chance of making a fool of yourself.
JONES: (As Rational responses): Well, my peers have known me now for 30 years
and even if I advance an opinion which doesn't merit the support of the
majority, that doesn't mean I'm no good or worthless.
DAVID: (As Automatic thoughts): Yes, but you'd be so humiliated you couldn't
stand it.
JONES: (As Rational responses): It might be a little embarrassing to say something
foolish, but I could survive and I could give myself credit for finally speaking
up and trying something new.
The use of externalization of voices has been developed by David

Burns in his work with patients on a one-to-one basis, and has grown
out of his personal interest and ability in the art of role playing. The
technique is equally well suited to the co-therapy setting. It is interesting
to note that Dreikurs (1950) described something very similar 30 years
ago:
A special type of situation is one in which the therapist actively interprets to
the patient the meaning of his actions while the other therapist 'argues from
the point of view of the patient's private logic.' ... In such a situation the
patient often recognizes his faulty perception as he sees the therapist using
his own mechanisms. (pp. 223-224)
Role playing may prove to be one of the best forms of intervention in

multiple therapy for both apprentice and patient.
2. Communication Training Using Role Playing. Role playing also can
be used to help the patient with his or her interpersonal problems. Real
life situations can be re-created and adaptive reactions modeled. The
presence of two therapists allows for a variety of interactions. For in-

stance, the patient initially might take the role of a hostile critic and the
therapist can model adaptive responses. Then the roles might be re-
versed. Finally, both therapists together can play critics and allow the
patient to defend himself.
Examples of situations we have dealt with in this way include:
1. Coping with criticism from a spouse, or at work.
2. Handling a difficult teenager who misbehaves and refuses to
talk.
3. Facing a job interview.
4. Initiating and maintaining a conversation with a stranger you
might wish to date.
5. Responding to a stranger without embarrassment.
3. Reformulation. Another valuable technique open to two therapists
is "reformulation," using different words to convey the same message.
If the patient does not understand an explanation or suggestion given by
one therapist the co-therapist can repeat it in his own words. The alter-
native phraseology is often very helpful to the patient. The same meth-
od of reformulating the other therapist's message is also worthwhile
when a particularly important point is being put across.
4. Two-Way and Three-Way Dialogue. The presence of two therapists
often means that there are times when they discuss the progress of the
session or theoretical points about what is happening. This may slow
down the session or digress from the main point; if used judiciously,
however, it can be of great value for the patient and the apprentice.
Actually observing two other people talking about his or her problem
can help the patient to distance him or herself from it. The therapist and
apprentice can gain by discussing their ideas at the moment of concep-
tion in the session, and the patient can give feedback on their appropri-
ateness. When this works well the initial two-way dialogue becomes a
three-way interaction in which patient, therapist, and apprentice gener-
ate ideas and work toward a clearer understanding of the problems
involved and the patient's own view of them.
Here is an example of how discussion between the two therapists in
the session actually can help the patient. The therapists have just been
giving rational responses to the patient's fears about speaking in groups:
STIRLING: I am wondering if we were presenting too much of a mastery model. If

we were to present more of a coping model in our rational responses ... by
talking about how embarrassed we feel, but how we're managing to overcome
it. Do you think that would be more useful?
THE Al'I'RENTICESHIP MODEL 311
DA vm: What we are doing is like a karate model.

STIRLING: Yes.
DAVID: You know when you take karate classes they get up and hit you in the
face. They don't actually make contact. As you learn by practicing certain
maneuvers to deflect your opponent's most vicious blows you overcome your
fear of people attacking you because you have ways to handle it. You become
calm in the face of battle. I think that's very much the way we are working.
What are you suggesting ... that might raise perfectionistic expectations?
STIRLINC: Yes, but also there is experimental evidence that the more effective
model is the one who has difficulties but can be seen to be coping with them.
This may get better results than if you model the thinking process of someone
who seems to have complete mastery of the threatening situation. It may
seem more realistic to the patient who is feeling overwhelmed or hopeless.
This dialogue brought out the possibility of a different strategy for

dealing with this man's problems with embarrassment in groups, that
is, demonstrating how to cope with anxiety. The patient was next asked
if the mastery model really did induce perfectionistic tendencies in him.
The therapist then demonstrated two types of rational responses and
the patient indicated which of the two approaches he found most help-
ful. The patient was in this way drawn into the planning of his own
therapy and allowed to give his reactions to the methods being used.
PATIENTS' REACTIONS TO Co-THERAPY
Since the viability of apprenticeship as a training model depends on

the willingness of patients to participate in a time-limited co-therapeutic
experience, we studied their reactions to these sessions. Twenty-two of
the patients seen were given a therapy session feedback form containing
questions similar to those in Table 2. The majority of responses were
positive ones. Seventy-two percent of patients said that they found the
experiment very useful and 100% agreed that this type of training would
be useful for other trainees and patients. Some patients found the pres-
ence of an additional therapist embarrassing, but most (86%) were not
embarrassed at all. Only two of the patients felt there were issues that
they could not discuss in the trainee's presence.
The general consensus was that the two therapists worked well
together. Twenty-eight percent said that the presence of another thera-
pist slowed down the session and 23% felt that the smoothness of thera-
PY was interrupted but the rest of the patients (72%, 77%, respectively),
did not notice any disruption of the flow of therapy.
TABLE 1
Interventions Suited for the Two Therapist Model
Method Description of method Why this is suited to the two-therapist model
1. Externalization of Voices 1. Using a role-playing format the patient and thera- 1. A) If one therapist's rational responses are not
pist act out the patient's self-defeating automatic proving helpful the other therapist immediately can
thoughts and rational responses. For example, the take over using a different strategy, thus prevent-
patient, in the role of Automatic Thoughts might ing an impasse.
say: "Because you didn't get that promotion it B) One therapist can play the role of the patient
shows you're a total failure." The therapist, in the and model what the patient is expected to do. This
role of the Rational Responses, might replay: can greatly cut down the time necessary to train
"That's ali-or-nothing thinking. I've succeeded at the patient in the use of the method. By observing
many things in my life so I can't be a total failure. one therapist play his role while the other therapist
Let's find out why I didn't get the promotion and administers treatment, the patient can attain an
work on how to improve my performance in the objective frame of reference and more readily ob-
future." This verbal exchange continues with fre- serve how illogical and self-defeating his (or her)
quent role reversals. negative thoughts are.
2. Communication Training 2. The patient and therapist act out situations that are 2. A) If the patient does not find one therapist's
Using Role Playing difficult to the patient, such as dealing with hostili- verbal style acceptable the other therapist can sug-
ty, criticism, or rejection. By using frequent role gest an alternative approach.
reversals the therapist can model self-expression B) If the patient feels shy about the role playing,
and listening skills and then give the patient the the two therapists can demonstrate the method
opportunity to master these while "under fire." with one of them playing the patient's role. This
This provides insight as well as mastery. allows the patient to learn by watching and to
become more comfortable with the role-playing
method.
3. Reformulation 3. One therapist repeats what the other therapist has 3. This utilizes the experience and personal style of
said using his own words and his own personal both therapists. If only one therapist is present the
examples. The patient is more likely to challenge effect cannot be achieved.
his distortions if he finds both therapists agree.
The second therapist repeating the message adds
emphasis and may get closer to what is personally
meaningful to the patient.
4. Dialogue 4. The two therapists discuss the progress of therapy 4. The patient can be drawn into a three-way interac-
and possible direction. The patient can sit back and tion when he collaborates in planning his own
find out how the therapists perceive his problems. therapy.
He may gain a useful perspective but if he dis-
agrees he can give the therapists feedback on
where they have misunderstood him.
The results of the questionnaire (Table 2) are on the whole encour-

aging. In addition the patients came up with some interesting observa-
tions. The most frequently cited benefit from this method came from the
presence of a different perspective, for example, "It has been very useful
to have a second point of view. Sometimes someone who is not as
'intensively' involved as the primary therapist, but who has some
knowledge and training as a therapist can be more objective and often
has 'insightful' remarks or ideas. In this way the sessions were faster
moving, more 'intense' and, to my mind, that is extremely positive."
Other patients found the role playing helpful, while some found listen-
ing to the dialogue between the two therapists of use.
"A new perspective was added. It was interesting to hear the two
therapists talk together about the therapy and share possible interven-
tions and suggest new approaches." One patient found the apprentice's
input helpful in overcoming a block in therapy.
Since the work described in this chapter took place, the senior
therapist has had the opportunity to carry out co-therapy on a more
limited basis with two other participants. The first was an untrained
observer (a journalist) who just sat in sessions and the second was an
untrained participant (also a journalist) who did participate in the
therapeutic role playing under the therapist's supervision. A compari-
son of some of the patient's responses is given in Table 3. Although the
number of patients involved in the two most recent collaborations are
smaller than the first, some interesting comparisons are suggested. The
trainee therapist consistently·is given the most favorable ratings while
the observer is given the least favorable. The untrained participant
comes somewhere between the two throughout. This suggests that
there are in fact benefits for the patient from the apprenticeship model
and that an active trainee is less embarrassing than a passive one. The
fact that the untrained participant received ratings that were nearly as
good as the apprentice therapist's would seem to support Dreikurs's
claim that co-therapy is suitable for therapist training and does not re-
quire therapists of equal capacity as proposed by Whitaker et al. (1950).
These findings also have implications concerning the potential for train-
ing of lay counselors, such as nurses, clergymen, and others, in cogni-
tive techniques and confirm the probable benefits of cognitive group
therapy.
These preliminary investigations suggest that the apprenticeship
model may be of positive benefit to patients as well as student thera-
pists. Further research is needed to find out if this subjective effect is
reflected by a speedier symptomatic improvement or better sustained
recovery.
THE NATURE AND PowER oF Co-THERAPY
In our hands, the apprenticeship model appeared to be surprisingly

effective. We observed patients who had been refractory to drug therapy
and to individual psychotherapy over a period of years experience a
change in mental outlook along with a substantial reduction of symp-
toms after a small number of sessions. The uniformly high ratings on the
patients' evaluations of these sessions attest to their enthusiasm (See
Table 2). There are two possible explanations of this phenomenon. First,
although the apprentice in this experiment was a novice, he proved to
be a highly talented therapist. The skill of two therapists working to-
gether as a team may have simple additive effect. Second, there may be
TABLE 2
Patient's Reactions to the Apprenticeship Model
A Moderate
Not at All A Little Amount Very Much Yes No
1. OveraH did you find this

experience useful? 0" 5 23 72
2. Do you consider that the
presence of another
therapist added to the
value of the session? 0 13 23 64
3. Would this type of train-
ing be helpful for other
trainee therapists and
patients? 100 ()
4. Was the presence of an
additional therapist em-
barrassing? 86 9 5 ()
5. Were there any issues
you could not discuss
because of the two thera-
pists? ]() (•o
6. Did the two therapists
work well together? lOf' ()
7. Did you feel that the
three-way approach:
a) slowed down the
session? 72 23 5 0
b) interfered with the
smoothness of
therapy? 77 23 0
~~scores are percentages of answers. Sample N = 22.

316 STIRLING MooREY AND DAVID D. BuRNs
TABLE 3
Comparison of Patients' Respones to Three Participants
A Moderate
Not at All A Little Amount Very Much
1. Overall value of experiment

Trainee therapist" Qd 5 23 72
Untrained participantb 0 14 29 57
Untrained observerc 30 40 30 0
2. Value of therapists presence
Trained therapist 0 13 23 64
Untrained participant 14 14 29 43
Untrained observer 50 30 20 0
3. Embarrassment due to par-
ticipant
Trained therapist 86 9 5 0
Untrained participant 71 29 0 0
Untrained observer 60 20 10 0
"N = 22.
bN = 7.
<N = 10.
dScores are percentages of answers.
something specifically powerful about this two-on-one treatment model.

This could be mediated by specific technical effects made possible by the
two therapist model or by so-called nonspecific interpersonal factors
that were activated by the presence of the apprentice.
There is probably some truth in both hypotheses. The apprentice
made effective contributions because he combined two important
qualities. First, he demonstrated warmth and empathy which fostered
trust and allowed patients to open up readily in his presence. They
found no difficulty in sharing their thoughts and feelings with him. He
perceived patients' mind sets and value systems accurately and they
sensed no hostility or judgmentalism. This created strong rapport which
provided the fertile soil for technically meaningful interventions.
His second asset was that he utilized a "pure" cognitive methodol-
ogy that was relatively uncontaminated by prior training in other schools
of treatment. He made no "dynamic interpretations" but formed hypoth-
eses based on the data-the patients' automatic thoughts. His therapeu-
tic interventions primarily involved attempts at altering the patients'
perceptions using straightforward cognitive techniques. Because he was
effective in suggesting alternative and more objective ways for patients to
interpret painful situations, he was able to facilitate rapid attitudinal
change.
Was there also something specifically beneficial about the two-

therapist model? According to cognitive theory, emotional and behav-
ioral change ultimately is mediated by a change in perception. The pro-
cess of attitude and perception modification can be speeded up consid-
erably by the presence of two therapists working as a team, because if
one therapist becomes bogged down the other therapist immediately
can intervene and suggest a fresh and different approach.
For example, a depressed woman had been stuck for many years in
the pattern of distortion called "personalization": She was excessively
self-blaming and consistently assumed that any negative feeling or prob-
lem her husband or children might have indicated she was "a failure."
Although the list of potentially helpful interventions for the personaliza-
tion error is lengthy, this particular mind-set, like many others, can be
quite refractory to modification. The therapeutic process can reach an
impasse when the therapist begins to run out of creative ideas and
experiences frustration. He then may view the patient as "stubborn" or
"difficult" or "resisting treatment." At this point the patient is likely to
sense the therapist's tension and may become increasingly self-critical.
Because of the patient's tendency to personalize, she is likely to tell
herself that she is also to blame for upsetting the therapist and conclude
that she is a failure as a patient as well. The therapist, sensing the
patient's worsening depression may in turn feel even more inadequate
and frustrated. Essentially, the two become locked in a foil-a-deux.
This phenomenon rarely occurs with the two-therapist model, be-
cause the other therapist can intervene and suggest an alternative strat-
egy that will infuse new life and vitality into the session. This raises the
probability that each session will be productive for the patient. It is as if
both therapists provide ongoing preception and feedback for each other,
and the patient's self-defeating attitudes have only the slimmest chance
for survival against what becomes a profusion of alternative frames of
reference and ways of intervening. Each therapist helps the other avoid
falling into mental traps and power struggles with the patient. Slow
points and lulls in therapy are reduced and often entirely circumvented.
Since the personal style and background of each. therapist is likely to be
different it seems quite easy for one to provide a meaningful direction
when the other feels temporarily stymied.
The overall effect was that sessions progressed at a rate that ap-
peared to be greater than either therapist could achieve alone. It may be
that the two-therapist model, while more costly, 1 might prove beneficial
1 The cost is not a factor when one therapist functions as an apprentice since there is no
additional charge.
and actually cost-effective in treating refractory patients who commonly

waste months and years in treatment with a single therapist without
measurable results. This is the general consensus from the literature
(Whitaker, Malone, & Warkentin, 1956; Watterson & Collinson, 1974;
Treppa, 1971), but there has been little systematic research directed at
the following questions: (1) Is the two-therapist method actually more
effective in treating mood disorders? (2) Does the increased efficacy
simply result from the enthusiasm that is generated by the presence of
an additional therapist or are there other more specific effects occurring?
(3) What are the most useful two-therapist methods and strategies? (4)
What mechanisms for change can be mobilized more effectively when
two therapists are present?
Finally, we might begin to consider how our experience of the ap-
prenticeship model fits into the framework of multiple therapy as prac-
ticed by others. We have been struck by the importance of the relation-
ship between the two therapists and what Treppa describes as the
"therapists' spontaneous and reciprocal interaction." The achievement
of what has been called "social democracy" seems to be one of the
important nonspecific factors involved. However, our version of co-
therapy would seem to be somewhere between the descriptions of
"multiple therapy" and "co-therapy" given by Treppa (1971) and
Mullan and Sanguiliano (1964). Cognitive therapy requires a structured,
problem-solving approach allowing therapists to adopt particular fixed
roles from time to time. He would seem to fit the description of co-
therapy given by Treppa. Nevertheless cognitive co-therapy also re-
quires a collaboration between patient and therapists and a free atmo-
sphere where all the participants can work together. This would seem to
fit the description of what the above authors see as the superior, more
existential "multiple therapy": "Multiple therapy is a cooperative effort;
the full therapeutic impact of this technique is realized only when the
therapist-therapist relationship is characterized by trust, emotional har-
mony, and collaboration" (Treppa & Nunnelly, 1974, p. 71). It may be
that the apprenticeship model falls somewhere between these two forms
of directive and nondirective co-therapy. Again we await research to
elicit what factors contribute to the effectiveness of this method.
APPRENTICESHIP AND PRECEPTION
The apprenticeship model presents a number of opportunities to

the student that are not available in traditional supervision (Table 4).
These arise in two main areas: observation of the senior therapist, and
THE APPRENTICESHIP MoDEL 319
feedback from the senior therapist. The apprentice can watch his or her
teacher at close quarters and absorb nonverbal as well as verbal style.
The availability of the supervisor as a model may speed up the time
taken in learning cognitive therapy. In any other form of psychotherapy
training modeling has to take place at a distance through videotapes and
audiotapes. Conversely, the therapist can observe the student more
closely than in the conventional training format. The.apprentice's first
attempt can be observed sympathetically and modified, under direct
supervision. If he or she gets stuck it is possible to ask for advice then
and there without having to wait until after the session. There are,
however, areas of therapeutic skill that this model cannot teach. In the
apprenticeship model the senior therapist is in control, or the control is a
joint effort. In conventional supervision the trainee has complete control
of his individual therapy session. This allows for experience in planning
long-term strategies, whereas in apprenticeship the strategies are short-
term ones devised and tested within the session. The rewards in super-
vision are internal, coming from a feeling of mastery in holding a session
on one's own, and from developing a close one-to-one relationship with
the patient. The apprentice is externally rewarded by the senior thera-
pist's approval. It can be argued that the three-way session can be op-
timally useful to someone who also has experience of psychotherapy,
and it is certainly true that the broader considerations of where the
therapy is going and when to terminate can be learned primarily in the
traditional manner.
The apprenticeship model is not such a radical departure from con-
ventional medical training in which the intern, resident, and attending
physician work together as a team; but this is rarely done in the training
of psychologists and psychiatrists who are supposed to figure things out
on their own because the relationship between the therapist and patient
is viewed as sacred. In fact the team approach nearly always works in
the patients' interest and can protect the patient from certain errors of
inexperience. These include:
1. Failure to inquire about suicidal impulses or to intervene effec-
tively
2. Mistakes in diagnosis
3. Being trapped in a sexual or romantic relationship with a patient
4. Insensitivity about the patient's value system
5. Inability of the therapist to recognize his own distortions or self-
defeating reactions to difficult patients
6. Inability to develop a focussed meaningful problem-solving
agenda coupled with specific strategies for change such that the
therapy moves forward instead of getting bogged down
TABLE 4
Comparison of Apprenticeship and Preception
Apprenticeship Preception
Modelling supervisor's skills: Verbal guidance from supervisor

1. Defining problems and
devising strategies
2. Establishing rapport
3. Handling difficult patients
Guided use of techniques Post hoc suggestions
Short term strategies Experience in long-term strategies
Rapid, specific feedback Delayed, general feedback
External reward: praise Internal reward: mastery
A period of apprenticeship might well help the novice avoid these

mistakes when he or she participates in individual psychotherapy. An
integrated program in which the trainee receives both apprenticeship
training and preception of individual therapy might be optimal.
The experience of others in their use of three-way therapy for train-
ing is gratifying (Dreikurs, Schulman, & Masak, 1952; Haigh & Kell,
1950; Rosenberg et al., 1968) but as yet the evidence is merely anecdotal.
Because of our enthusiasm for what was admittedly a small trial, we
would like to see the approach evaluated on a larger scale to see if the
potential for training is as great as we believe it to be.
SUMMARY
We have found cognitive co-therapy an exciting and rewarding ex-

perience. Cognitive techniques easily can be applied to the three-way
approach, and we have begun to develop some cognitive strategies spe-
cifically for this model. The apprenticeship model has much potential for
training, but in addition can be a valuable experience for both the senior
therapist and the patient: We have seen remarkable symptomatic im-
provement in our co-therapy sessions. Much of our experience has
agreed with other writers on co-therapy although they have written
from a psychodynamic viewpoint. Despite our encouraging results we
have to stress that our research like all the previous literature is anecdo-
tal and we await objective investigations of this method. We hope that
others will try the apprenticeship model for themselves and discover its
benefits for student and patient alike.
REFERENCES
Adams, W. R., Ham, T. H., Maward, B. H., Scali, H. A., & Weisman, R. A naturalistic
study of teaching in a clinical clerkship.Journal of Medical Education, 1958, 33, 211-220.
Guilford, 1979.
Dreikurs, R. Techniques and dynamics of multiple psychotherapy. Psychiatric Quarterly,
1950, 24, 788.
Dreikurs, R., Schulman, B. H., & Masak, H. Patient-therapist relationship. I. Its advan-
tages to the therapist. Psychiatric Quarterly, 1952, 26, 219.
Haigh, G., & Kell, B. L. Multiple therapy as a method of training and research in psycho-
therapy. Journal of Abnormal Social Psychology, 1950, 45, 659.
Lott, G. M. The training of non-medical cooperative psychotherapy by multiple psycho-
therapy. American Journal of Psychotherapy, 1952, 6, 440.
Matefy, R. E., Solanch, L., & Humphrey, E. Behavior modification in the home with
students as co-therapists. American Journal of Psychotherapy, 1975, 29, 212.
Mullan, H., & Sanguiliano, I. The therapist's contribution to the treatment process. Springfield,
Ill.: Charles C Thomas, 1964.
Reeve, G. H. Trends in therapy: V. A method of coordinated treatment. American Journal of
Orthopsychiatry, 1939, 9, 743.
Rosenberg, L., Rubin, S. S., & Finizi, H. Participant-supervision in the teaching of psycho-
therapy. American Journal of Psychotherapy, 1968, 22, 280.
Strauss, B. V. Teaching psychotherapy to medical students. Journal of the Association of
American Medical Colleges, July 1-6, 1950.
Treppa, J. A. Multiple therapy: Its growth and importance. American Journal of Psycho-
therapy, 1971, 25, 447.
Treppa, J. A., & Nunnelly, K. G. Interpersonal dynamics related to the utilization of
multiple therapy. American Journal of Psychotherapy, 1974, 28, 71-86.
Watterson, D., & Collinson, S. Explorations in co-psychotherapy. Canadian Psychiatric
Association Journal, 1974, 19, 572.
Whitaker, C. A., Warkentin, J., & Johnson, N. L. The psychotherapeutic impasse. Ameri-
can Journal of Orthopsychiatry, 1950, 20, 641.
Whitaker, C. A., Malone, T. P., & Warkentin, J. Multiple therapy and psychotherapy. In
F. Fromm-Reichman & J. L. Moreno, (Eds.), Progress in psychotherapy (Vol. 1). New
York: Grune & Stratton, 1956.
14
The Group Supervision Model
in Cognitive Therapy Training
ANNA RosE CHILDRESS AND DAVID D. BuRNS
INTRODUCTION
In the spring of 1980, several beginning therapists-psychiatry residents

and psychologists at the University of Pennsylvania-attended a series
of introductory seminars in cognitive therapy presented by the second
author. Because several of the novice therapists were excited by their
initial exposure to cognitive therapy, ongoing group case supervision
was arranged. The decision to meet as a group had pragmatic origins:
Dr. Burns could not offer individual supervision to all those who wished
it. In retrospect this limitation was fortunate. We rapidly discovered, to
the delight of both students and supervisor, that group supervision and
cognitive therapy techniques were natural complements for each other;
the inode of supervision actually facilitated the teaching and learning
process and produced an experience that was unexpectedly rich. In this
chapter, we present the group supervision model we used, discussing
its particular-and often unique-advantages for the therapist-in-train-
ing, the supervisor, and the patient.
FoRMAT UsED IN CoGNITIVE THERAPY GRouP SuPERVISION
As a foundation for group supervision in cognitive therapy, trainees

are given exposure through lectures, reading, or demonstrations to basic
cognitive therapy techniques and interpersonal/communication skills
ANNA RosE CHILDRESS AND DAVID D. BuRNS • Department of Psychiatry, School of

Medicine, University of Pennsylvania, Philadelphia, Pennsylvania 19104.
323
324 ANNA RosE CHILDREss AND DAviD D. BuRNS
(see Appendix A for a description of basic techniques). As basic reading

in the theory and techniques of cognitive therapy, trainees were encour-
aged to read Burns (1980) and Beck, Rush, Shaw, and Emery (1979). This
foundation gives the trainees a common language and background, al-
lowing the group supervision to proceed smoothly, without time lost in
defining terms or basic concepts. Regular weekly sessions (1-P/2 hours)
of group supervision are arranged. The group size is limited-usually
five to six members--to maximize individual involvement. For each ses-
sion, the approach is problem-oriented, with attention focused upon
generating specific therapeutic strategies. Typical topics might include
how to set a specific agenda for a vague, unfocused patient; how to
develop rapport and collaboration with an angry, suspicious, or opposi-
tional patient; how to train patients to identify and talk back to distorted
negative thoughts; how to manage suicidal patients; how to help pa-
tients pinpoint and restructure self-defeating belief systems; how to mo-
tivate apathetic patients to develop a schedule of satisfying activities,
and so forth.
Each weekly session begins with the supervisor's request for case
material. Volunteers are never in short demand, as trainees are not
placed "on the hot seat": the atmosphere is one of group support and
mutual teaching. The trainee will present a "problem case"-one in
which progress has been slow or difficult. The initial case vignettes are
brief, presented with necessary background information, but with em-
phasis on defining and solving therapeutic problems in the here and
now.
SUPERVISOR: Who has some case material for us?

SAM (trainee): I have a case-an intelligent, articulate 35-year-old woman with a
two-year history of chronic depression and anxiety attacks. The depression
began following her resignation from a high prestige administrative job. She
says she resigned because she was too anxious to work after her complaints
about the performance of one of her staff resulted in his dismissal. She hasn't
worked in two years, and now lives with her two children in her mother's
home. She believes her usual activities offer no interest or pleasure. She
complains of blue mood, panic attacks, difficulty sleeping, lack of appetite,
and lack of energy. She spends most of her time as a virtual recluse in her
mother's home. In our last session, we talked about her looking for some kind
of work. Her automatic thoughts included themes of hopelessness ("I can't
ever see things changing"); helplessness ("I can't control my life-I'm not
strong enough for work"), and low self-esteem ("I am just a sham ... and
the interviewer would see it"). She also predicts, "I can't go out for a job
interview-! would get an anxiety attack ... and I wouldn't be able to hold
THE GROUP SUPERVISION MODEL IN COGNIT!VE THERAPY TRAINING 325
the job anyway, the shape I'm in .... "Right now, I can't seem to get therapy
off the ground with this patient. She has problems in so many areas it should
be easy, I guess, but she seems to get so overinvolved in talking about her
symptoms (her weight, her appetite, her insomnia, her anxiety, and so forth)
that we never get anywhere. And she is very reluctant when I want her to
write down her automatic thoughts and work out rational responses. What
should I try?
(At this point the supervisor may quickly solicit possible approaches from others
in the group.)
SUPERVISOR: There would seem to be a number of possible approaches. Let's

hear some ideas. John?
JOHN (trainee): Well, you could start working with the patient in other ways to
change her thoughts-such as using the Pleasure Predicting sheet to test her
belief that nothing gives her pleasure anymore. It might give her some relief
and encouragement to see that she can still experience some pleasure/satisfac-
tion, and then she might be willing to work on writing down her thoughts.
JAMES (trainee): Along those lines, you might try role playing some of her auto-
matic thoughts, verbally naming the cognitive distortions and working out
rational responses ....
MARY (trainee): Maybe the idea of "going for a job interview" is too overwhelm-
ing for this patient right now-maybe you could instead talk about that area by
breaking the task down into small parts that would seem more manageable, like
looking for an ad or making one phone inquiry-essentially working out a
graded task assignment that would elicit fewer anxiety producing thoughts.
JANE (trainee): I think it might be useful to start by finding out her thoughts
about writing down her automatic thoughts/rational responses ... we don't
know why she is reluctant, but it could be for any number of reasons-that
she thinks it is useless, that nothing will work; that she thinks you will judge
her harshly if she doesn't perform well, and so forth. You might be able to get
at this by using externalization of voices-having her voice her inner dialogue
about writing down her thoughts, and then work together on some rational
responses to those thoughts.
SUSAN (trainee): Maybe she's reluctant to work by writing down her thoughts
because she feels you must appreciate her distress first; that this writing-down
task seems cold and impersonal. If you've been strongly focused on the writ-
ing task and feel frustrated by the fact that she's not working, it might be time
to use some interpersonal/communication skills ... a good dose of empathy and
inquiry might quickly dissolve her reluctance.
SUPERVISOR: We have a lot of good suggestions here ... all of them may be
useful at one point or another. I think right now a first step might be to find
out about her reluctance, if possible. Maybe we can combine Jane's and Sus-
an's suggestions, using initial empathy and inquiry, then leading the patient
to voice/externalize her automatic thoughts about writing down her thoughts,
326 ANNA RosE CHILDRESS AND DAviD D. BuRNS
and so on. John, why don't you play the patient, and I'll take on the role of
therapist for the moment.
In this example, the supervisor encourages group members to contrib-

ute ideas spontaneously, in brainstorming fashion. He then reinforces
the suggestion making and leads the work in a direction that might be
most useful to the therapist and the patient at that point. In this case,
sensing the therapist's frustration ("not getting anywhere") and appar-
ent focus on the "writing-down" task, he leads the work in the direction
of increased rapport/empathy with the patient, while still emphasizing
cognitive techniques-eliciting the patient's thoughts about the writing-
down task, and working on rational responses to these thoughts.
In a full session, the preceding exchange would constitute only a
small initial segment. The subsequent work could take a multitude of
directions, with the supervisor perhaps modeling empathy/inquiry; re-
assigning the therapist/patient roles to other group members; rapidly
alternating patient/therapist roles; eliciting rational responses to the pa-
tient's negative automatic thoughts; and, finally, outlining an integrated
strategy-or several possible strategies-for the trainee's next session
with the patient. As the trainees become more practiced, group work
proceeds rapidly, allowing discussion of more than one vignette per
session. For each case, the approach remains two-fold, with emphasis
upon the acquisition of technical and interpersonal skills.
ADVANTAGES FOR THE THERAPIST-IN-TRAINING
After only a few weeks of work, our trainee therapists began to

recognize distinct advantages of group supervision in comparison with
other modes. These advantages were apparent in areas of both technical
growth and professional confidence/self-esteem factors.
Technical Advantages
One of the most obvious technical advantages is that a group super-
vision format gives each trainee exposure to a far greater number of
"problem" cases than he or she would encounter if limited to his or her
own personal case load. This broader exposure means the trainee will
gain familiarity with the full gamut of cognitive-behavioral techniques
stimulated by the larger number of cases. In group supervision the
trainee not only learns from the cases he or she personally presents, but
THE GROUP SUPERVISION MODEL IN CoGNITIVE THERAPY TRAINING 327
also from each case that others present as well. Each new case repre-
sents an opportunity to evolve therapeutic strategies rapidly and then to
practice the cognitive-behavioral techniques required to implement
these strategies. The result of this experience can be dramatic, rapid
learning. This is perhaps understandable if we recognize that trainees
are, in a sense, "treating" and learning from four to five patient pools in
addition to their own.
The group context also facilitates the learning of interpersonal/com-
murtication skills. When a trainee assumes the therapist role in a case
vignette, the supervisor and other group members can provide immedi-
ate feedback on the therapist's interpersonal handling. of the "patient."
The novice therapist immediately can find out how his or her approach
is "heard" from several individual perspectives, and can practice alter-
ing that approach in accord with observations distilled from the group
comments. The group context is supportive and nonjudgmental, mak-
ing group comments welcome as opposed to dreaded.
In addition to providing exposure to multiple case sources of feed-
back on technical and interpersonal skills, group supervision gives the
trainee therapist another advantage: the presence of multiple role modes
for refining skills in both these areas. In individual supervision, the
trainee often is left with the choice of adopting the technique/style of the
supervisor (which may be limiting, uncomfortable, or inappropriate), or
gradually developing his or her own working methods by trial-and
very often, error. Group supervision largely eliminates this difficulty;
the novice has multiple role models-peers and supervisor-for model-
ing cognitive techniques and interpersonal skills. The trainee can pick
and choose freely among these models, adopting techniques and com-
munication skills as he or she finds it useful. The greater availability of
the role models increases the likelihood that the trainee will find tech-
niques that are more comfortable, more natural, and thus probably more
effective for him or her as a therapist.
Professional Confidence/ Mood Factors

Although increased therapeutic effectiveness is an important bot-
tom line, group supervision in cognitive therapy also yields personal
and professional benefits for the beginning therapist. Most of these
benefits have to do with reduced anxiety, increased confidence, and
increased immunity to buying into the patient's feelings of hopelessness
and frustration.
As beginners, novice therapists often are somewhat anxious and
328 ANNA RosE CHILDRESS AND DAVID D. BuRNs
insecure about their therapeutic skills. Individual supervision with a

seasoned clinician does little to allay these concerns, since the experi-
enced therapist frequently appears to "know more" than the trainee.
Group supervision, on the other hand, provides a more realistic refer-
ence group against which the beginner can assess his or her developing
skills. In the group, he or she can observe that others-even skilled
others-can have "problem" cases. This realization in itself often serves
to reduce anxiety and insecurity about professional competence. Com-
paring skills within an appropriate reference groups, with a realistic
appraisal of developing strengths and weaknesses, actually can increase
confidence.
The group supervision process also proves an effective antidote to
the frustration and hopelessness experienced by beginners in the face of
a difficult case. The process of arming the therapist with a number of
fresh approaches can help reduce the therapist's feelings of frustration
and hopelessness. Trainees commonly report coming to the conference
feeling overwhelmed by a particular patient and leaving the conference
feeling much more confident and optimistic.
Finally, group supervision may be able to prevent the novice thera-
pist from suffering embarrassment or other difficulty resulting from in-
appropriate handling of a case. Alert group members may be able to
"troubleshoot" a difficult case before problems occur by anticipating pos-
sible crises (suicidal threats, sexual overtures, acting out, and so forth)
and pre-planning a course of action with the training therapist.
It also can be helpful for group members to use cognitive techniques
in coping with anxiety and other so-called countertransference reactions
that develop in dealing with difficult patients (for a more detailed dis-
cussion of this approach, see Burns, 1980, pp. 349-360). Therapists are
encouraged to write down their automatic thoughts and to develop
rational responses to them. Other group members can be helpful in
facilitating this. For example, a therapist felt angry and guilty when a
patient persistently failed to do self-help assignments in spite of prom-
ises to the contrary. The therapist had these automatic thoughts: "My
patient is being passive-aggressive. I'm trying my best, so he should do
his part. Actually I shouldn't be reacting this way. A therapist should be
more objective. A professional shouldn't get so angry. Other therapists
would be handling this better." With the help of the group, these ra-
tional responses were generated: "It won't be helpful to blame him or to
label him as passive-aggressive. It would be far better to find out why he
has difficulty doing self-help assignments by asking about his automatic
thoughts. It's a fairy tale that therapists never feel angry or frustrated.
While it's not comfortable to feel this way, it shows that I'm quite human
THE GROUP SUPERVISION MODEL IN COGNITIVE THERAPY TRAINING 329
and I don't need to be ashamed of that. Over time, I will learn not to feel
so upset when patients procrastinate since this is a common therapeutic
problem." The therapist reported that looking at it this way helped him
feel some relief. The group then helped him develop a list of strategies
for breaking the therapeutic log-jam with this particular patient.
It can be noted that these benefits of the group supervision process
are really more than pleasant incidentals; therapists who are anxious,
insecure, underconfident, frustrated, and overwhelmed will have diffi-
culty delivering the best patient care, however good their intentions or
their technical skill. Increased control in these areas will lead to in-
creased therapeutic effectiveness.
ADVANTAGES FOR THE SUPERVISING THERAPIST
The group supervision model of cognitive therapy training also has

distinct advantages for the supervising therapist. Prominent among
these is increased time efficiency. Using a group supervision model, a
senior therapist can train six therapists in the same amount of time (one
hour per week) usually alloted for one trainee in individual supervision.
Training effectiveness is not sacrificed but actually may be enhanced. A
four- to six-fold increase in time efficiency, with no apparent loss in
teaching effectiveness, may endear this mode of training to supervisors
pressed for time but eager to teach and maintain contact with students.
Another advantage for the supervising therapist is the vast number
of "teaching tools" at his or her disposal. In individual supervision, the
supervisor's teaching is limited by his or her own imagination and that
of the single trainee. After a time, supervisor and trainee often evolve
certain predictable approaches or interactions that can block fresh, inno-
vative solutions. In group supervision, on the other hand, the training
potential is tremendously expanded. The supervisor may use any group
member or combination of group members to illustrate a strategy or
work out a technique. Each trainee not only learns while participating in
the exercise, but also functions as a tool so that others learn from him or
her. As training proceeds and the supervisor becomes more familiar
with the relative strengths and weaknesses of group members, he or she
can orchestrate the supervision appropriately. If a student is particularly
facile with rational responses, for example, the therapist may pair this
trainee with one who is less skilled at rational responding and then
encourage role playing of automatic thoughts/rational responses, with
rapid and frequent role reversals.
The group supervision format also serves as a natural forum for
330 ANNA ROSE CHILDRESS AND DAVID D. BURNS
discovery of new cognitive-behavioral techniques and refinement of

familiar techniques. These sessions provide an opportunity to examine
theoretical concepts underlying the techniques taught and to work on
theoretical refinements suggested by the clinical data at hand. Group
supervision sessions also may trigger research ideas and lead to experi-
ments that further understanding of cognitive therapy processes. Sever-
al promising studies of the relationship between cognition and mood
have been initiated by members of the preception group.
ADVANTAGES FOR THE PATIENT
Advantages for patient care may be apparent at this point, but are
worth stating. Group supervision provides a training ground in which
beginning therapists are given exposure to a wide range of cases and
techniques, increasing the probability that they will adopt an effective
approach for a given patient. This is especially important because of the
high incidence of suicidal impulses among patients being treated for
depression. Many research studies have documented that the patient's
belief he or she never can improve is based on illogical thinking and has
a high correlation with suicidal urges and attempts (Beck & Burns, 1978;
Beck, Kovacs, & Weissman, 1975; Wetzel, 1976). Since some patients
seem to have the capacity to persuade friends, associates, and even their
therapist that they are hopeless, the novice therapist may feel threatened
and be unable to pinpoint and reverse the distortions in the patient's
persistently pessimistic thinking. The group can help the therapist de-
velop effective strategies to reverse the patient's hopelessness and en-
gage him or her in a collaborative therapeutic relationship. Some of the
strategies developed by members of our group are now in press (Burns
& Persons, 1982).
The therapist receives grounding in interpersonal skills that facili-
tate communication with the patient, allowing the patient to feel under-
stood as well as "helped." The therapist himself is less anxious, more
secure, and more confident-a better executor of the chosen therapeutic
strategy. For a specific patient, multiple "case solutions" are generated
and considered by the group. The final therapeutic choice(s) will reflect
an optimal distillation of the supervisor's accumulated knowledge and
the group members' varied perspectives, maximizing the probability of
therapeutic success. A patient under the care of a group supervision
trainee enjoys the benefits of a patient with several doctors constantly
consulting and guiding treatment, but without the cost that actuality
would entail.
THE GROUP SuPERVISION MoDEL IN CoGNITIVE THERAPY TRAINING 331
TABLE 1
A Comparison of Apprenticeship, Individual Supervision, and Group
Supervision Cognitive Therapy
Apprenticeship Individual supervision" Group supervision
Modelling supervisor's Verbal guidance from su- Increased support/confi-

skills pervisor dence for trainee
Guided use of techniques Post hoc suggestions Multiple sources of feed-
back for trainee
Short term strategies Experience in long-term Exposure to larger num-
strategies ber of cases/techniques
Rapid, specific feedback Delayed, general feed- Increased therapeutic ef-
back fectiveness
External reward:praise Internal reward:mastery Increased time efficiency
for supervisor
Increased teaching effec-
tiveness for supervisor
"Group supervision also supplies these benefits.
COMPARISON OF INDIVIDUAL PRECEPTION, APPRENTICESHIP

AND GROUP SUPERVISION
In a recent article, Moorey and Burns (1982) compared several fea-

tures of individual preception versus apprenticeship. As seen in Table 1,
group supervision offers features characteristics of both these modali-
ties. A group supervision session often will include replay, commen-
tary, and ad hoc guidance characteristic of individual supervision, and
then rapidly shift to an in vivo treatment situation with all the immediacy
characteristic of an apprenticeship mode, but without the pressure of an
actual treatment situation. For the trainee, group supervision allows
exposure to a greater number of cases/techniques, provides increased
moral support, encourages a realistic assessment of skills relative to a
peer group, and offers multiple sources of feedback and ideas for the
management of difficult patients. Advantages for the supervisor include
increased time efficiency and increased teaching effectiveness.
SUMMARY
Group supervision has been used for training in other psycho-

therapies with varying success (Matarazzo, 1971; Traux & Carkhuff,
332 ANNA RosE CHILDRESS AND DAviD D. BuRNs
1967). At this point there are no studies that have determined em-
pirically the relative effectiveness of different supervision modalities in
either the teaching of cognitive therapy or in patient outcome measures.
Probably an ideal teaching model would utilize all these modalities. It
appears that group supervision is an outstanding teaching vehicle for
cognitive therapy training which offers multiple advantages to the train-
ee, supervisor, and patient.
APPENDIX
Techniques Introduced in Group Supervision in Cognitive

Therapy
A. Cognitive/behavioral techniques
1. Triple-Column technique: Patient writes down negative auto-
matic thoughts, the cognitive distortions they contain, and
possible rational responses to the thoughts in a three-column
format.
2. Daily record of dysfunctional thoughts: An elaboration of the
triple-column technique to include the situation giving rise
to the automatic thoughts and feelings caused by the auto-
matic thoughts. Degree of feeling and extent of belief in the
automatic thoughts are initially rated and then re-rated fol-
lowing work on rational responses.
· 3. Externalization of voices: The patient's inner dialogue-in the
form of automatic thoughts/ criticism, and so forth-is exter-
nalized, voiced, and acted out by the therapist and patient,
with focus on developing rational responses to the negative
automatic thoughts.
4. Role playing: Therapist and patient "play out" situations that
give the patient difficulty (such as job interviews or asking
someone for a date) with emphasis upon developing the
appropriate social skills.
5. Labeling of cognitive distortions: Patient is given a list of com-
mon cognitive distortions or "thought traps" and learns to
recognize the distortions inherent in his or her automatic
thoughts, recognizing that these distortions are the trigger
for negative feelings.
6. "Collecting evidence"-"Conducting experiments": Patient is
asked for confirming or disconfirming evidence to a given
THE GROUP SUPERVISION MODEL IN COGNITIVE THERAPY TRAINING 333
belief-and may be asked to conduct a test of the belief, that

is, to see if his or her spouse will reject him or her if they
disagree.
7. Pleasure predicting sheet: A before and after sheet used in help-
ing the patient to test his or her belief that nothing give him
or her satisfaction or that he or she cannot find pleasure in
doing things alone. The patient lists a variety of activities
with a potential for growth or enjoyment and predicts ahead
of time how satisfying each of them will be using a zero to
one hundred rating scale. After the activity has been com-
pleted, he records how satisfying it actually was, using the
same rating scale.
8. Graded task assignment: Large, seemingly overwhelming tasks
are broken down into small, manageable components and
then assigned to the patient.
9. Stress innoculation: The therapist assumes an attacking role,
bombarding the patient with increasingly difficult criticisms
that the patient in turn learns to counter, "innoculating" him
or her to future stress from those thoughts.
10. BIAS Test (Burns Interpersonal Attitude Scale): A 93-item scale
designed to pinpoint dysfunctional belief clusters that lead
to interpersonal conflict.
11. BDI (Beck Depression Inventory): A 21-item scale measuring
the severity of depression and useful in monitoring the pa-
tient's weekly progress.
B. Interpersonal/communication skills
These techniques are useful in management of the difficult, an-
gry, or "resistant" patient. They are used to increase rapport
and to decrease polarization/conflict. They also can be taught to
patients for their use in managing conflict or responding more
effectively to criticism.
1. Empathy
(a) Thought empathy: Paraphasing the other person's thoughts
to let him or her know that you understand what he or she is
thinking. For example, suppose the patient has not been
doing self-help assignments. When the therapist asks about
this the patient says "being told to do all this written home-
work is a pain in the neck. It's a waste of time. It's just like
being in school again." The therapist can say, "I take it you
think the written homework assignments wouldn't really
help you and they remind you of being in school again. Is that
how you see it?"
334 ANNA RosE CHILDRESS AND DAVID D. BuRNs
(b) Feeling empathy: Acknowledging the person's feelings be-

hind his or her thoughts, for example, the therapist might
say, "I can see how you might be feeling frustrated or bossed
around if you're being forced to do something that you're not
convinced will help you. Is that how you feel?"
2. Disarming: Finding the "grain of truth" in the other person's
argument (however unreasonable it seems) and repeating it
actually will have the paradoxical effect of melting opposi-
tional feelings. In the above dialogue, the therapist might
disarm the angry patient by saying, "It sounds like you need
more time to get your feelings off your chest and to receive
some feeling of support from me. Sometimes the therapy can
seem too preoccupied with techniques, and not sufficiently
warm and human. Is this how I've been coming across?"
3. Inquiry: Use of questions to find out more about the other's
thoughts and feelings, with the goal of turning negative crit-
icisms into a concrete problem, "What in particular did I say
or do that turned you off?"
4. Stroking: Expressions of positive regard for the other person
(even in the heat of disagreement) will tend to cool his or her
angry feelings and and make the person more receptive to
your point.
5. Tactful self-expression: Expression of thoughts, needs, and feel-
ings in a constructive, objective, noncoercive way.
6. Problem solving and negotiation: Define the problem in concrete
terms, developing options, and negotiating while taking into
account each person needs.
REFERENCES
Beck, A. T., & Burns, D. Cognitive therapy of depressed suicidal outpatients. InJ. 0. Cole,
A. F. Schatzberg, & S. H. Frazier (Eds.), Depression: Biology, psychodynamics and treat-
ment. New York: Plenum, 1978.
Beck, A. T., Kovacs, M., & Weissman, A. Hopelessness and suicidal behavior: An over-
view. Journal of the American Medical Association, 1975, 234, 1146-1149.
Beck, A. T., Rush, A. J., Shaw, B. F., & Emery, J. Cognitive therapy of depression. New York:
Guilford, 1979.
Burns, D. D., & Persons, J. B. Hope and hopelessness: A cognitive approach. In L. E. Abt
& I. R. Stuart (Eds.), The new therapies: A sourcebook. New York: Van Nostrand
Reinhold, 1982.
Matarazzo, R. Research on the teaching and learning of psychotherapeutic skills. In A.
THE GROUP SuPERVISION MoDEL IN CoGNITIVE THERAPY TRAINING 335
Bergin & S. Garfield (Eds.), Handbook of psychotherapy and behavioral change. New York:
Wiley, 1971.
Moorey, S., & Burns, D. D. The apprenticeship model of cognitive therapy training.
Unpublished manuscript, in press.
I raux, C., & Carkhuff, R. Toward effective counseling and psychotherapy: training and practice.
Chicago: Aldine, 1967.
Wetzel, R. D. Hopelessness, depression and suicidal intent. Archives General Psychiatry,
1976, 30, 1069-1073.
Index
ABC model Anxiety

depression groups, 26, 29-30 agoraphobia and, 199-200, 216n5
Rational-Emotive therapy, 48, 50, assessment of, 18
56-57, 58 family system and, 96
young adult chronic patients, 191 Rational-Emotive therapy, 49
Acceptance. See Self-acceptance young adult chronic patients, 187
Activity Inhibition measure, 158 Apprenticeship model, 303-321
Adlerian models, 2 history of, 303-304
Agenda setting nature and power of, 315-318
agoraphobia groups, 212 origin of, 204
depression groups, 18-20, 37 patient reaction to, 311-314, 315
self-control groups, 69-70 perception and, 318-320
sexual enhancement groups, 228-229 process of, 305-311
young adult chronic patients, 185 therapy session structure, 305-307
Agoraphobia, 199-220 three-way techniques, 307-311
behavioral explanations of, 199 Arbitrary inference, 5, 192
cognitive coping strategies for, 211 Assertiveness, 97-98
cycle in, 202 Assertiveness training, 218
psychotherapy group for, 216-219 Assessment
travel group for, 202-219 anxiety, 18
Alcoholics and alcoholism, 157-182 couples therapy, 109, 110-111
cognitive characteristics of, 158-159 depression, 18, 37
cognitive model of, 159-166 Rational-Emotive therapy, 48, 51
cognitive therapy for, 166-168 self-control therapy, 69
cognitive therapy protocol in, 169-180 Attention, young adult chronic patients,
group treatment for, 168-169 190-191
maladaptive conceptualizations in, Attitudes, 45, 62
164-165 Attribution of causality. See Causality
personality characteristics of, 158 attribution
psychotherapy and, 157 Attributions
Alcoholics Anonymous, 162-163, 179 couples therapy, 113-117, 126
Alcohol consumption, 278 young adult chronic patients, 193
AU-or-nothing thinking, 4 Automatic Thoughts Questionnaire, 18
family system therapy, 103
young adult chronic patients, 192
Alone-contented paradigm, 271 BASIC ID model, 8
Alone-deficit paradigm, 271 Beck Depression Inventory (BDI), 18, 68,
Aloneness, defined, 268 69, 167
American Psychological Association, 60 Behavior, sexual enhancement, 231-232
337
338 INDEX
Behavioral experiment, cognitions and, Cognition (Cont.)

130-131 sexual enhancement, 231
Behavioral strategies young adult chronic patients, 194-195
living alone groups, 271-272 Cognitive-behavioral interventions,
treatment, 8 131-135
Behavior change, cognitive change and, Cognitive-behavioral model, 120
127-149 Cognitive-behavioral processes, 68
Behavior modification, cognitive therapy Cognitive-behavioral strategies change
and, 1 and, 127-149
Behavior therapy couples therapy, 125-155
couples therapy, 126 Cognitive-behavior modification, 1
Rational-Emotive therapy compared, Cognitive dissonance, 45
62 Cognitive-learning approaches, 44
Belief systems (irrational). See Reality Cognitive model, 28-31
distortion Cognitive restructuring
Bibliotherapy collaborative set and, 126-127
couples therapy, 111 young adult chronic patients, 192-195
sexual enhancement, 231, 233 Cognitive strategies, 8
Blaming, couples therapy, 109, 113, 114, Cognitive theory, 25-27
126, 127, 131 Cognitive therapy, 1-9
Boston Veterans Administration Center definitions of, 2
for Problem Drinking, 160, 163 depression and, 12
history of, 1-2
homework, 8-9
California Psychological Inventory, 167 problem-oriented groups, 14
Catastrophizing simplicity myth in, 2-7
agoraphobia treatment, 208, 209, 210 Collaborative set
young adult chronic patients, 192-193 defined, 126
Causality attribution, self-control model, individual cognitive restructuring,
68, 83-86 126-127
Center for Cognitive Therapy (Phila- induction and enhancement of,
delphia), 186 138-139
Classical Rational-Emotive therapy, 44 Communication
See also Rational-Emotive therapy couples therapy, 112
(RET) Rational-Emotive therapy, 58
Client-therapist relationship. See Thera- sexual enhancement, 223, 231
pist-client relationship young adult chronic patients, 188
Clitoris, 221, 230, 235-236 Communication training, 309-310
Closed groups, 16 couples therapy, 117
Coaching Community living, 183
agoraphobia groups, 216 Competitive feelings, 146
couples therapy, 112 Comprehensive Rational-Emotive thera-
Cognition py, 44
agoraphobia, 200-201 See also Rational-Emotive therapy
behavioral experiment and, 130-131 (RET)
couples therapy and, 107-108 Confidentiality
family system and, 95, 96-97, 98, group setting, 20
103-104 Rational-Emotive therapy, 53
mood and, 72 sexual enhancement groups, 234
Rational-Emotive therapy and, 61 Confirmable reality, 194
INDEX 339
Conjoint sessions Depressives, alcoholics compared,

appropriateness of, 137 160-161
couples therapy, 142-146, 152-153 Desensitization
individual session compared, 137 agoraphobia treatment, 203
purpose of, 135-136 sexual enhancement, 232
results of, 136-137 Disqualifying the positive, 4-5
sexual enhancement, 222-223 Dissuasion, 45-46, 51
Co-therapists and therapy, 16 Distorted reality. See Reality distortion
couples therapy, 112 Duration
history of, 303-304 group meetings, 17
sexual enhancement groups, 225 Rational-Emotive therapy, 59-60
training by (See Apprenticeship self-control groups, 69
model) sexual enhancement groups, 228
young adult chronic patients, 186 travel groups, 204-205
Couples therapy, 107-123, 125-155 Dysfunctional beliefs, 31-35
attributions correction, 113-117 Dysfunctional Thought Form, 132, 134
cognition and, 107-108 Dysfunctional Thoughts Record, 38
cognitive-behavioral model and,
119-122 Eating, living alone groups, 277-278,
expectations modification approach, 293-294
108-113 Echoing, 209
individual sessions, 127 Emotional reasoning, 5-6
maladaptive formulas in, 149-153 Empathy technique, 140
self-instructional procedures, 117-119 Ethics, 54, 60
Covert self-reinforcement, 90-91 Etiology, 23-25
Credibility, 46-47 Expectations
Criminality, 54 couples therapy, 108-113
family system therapy, 102
group setting, 21-23
Deinstitutionalization, 183 Expressiveness training, 218
Delayed consequences, 79-83 Externalization of voices, 307-309
Delusional thinking, 194
Dependence, 158 Facilitator, 58
Depression Family
assessment of, 18, 37 agoraphobia treatment, 219
family system and, 96 individual interactions and, 95-98
see also Depression therapy Family system therapy, 95-106
Depression Adjective Check List, 69 contact establishment, 98-99
Depression therapy (group format), individual and family interactions pat-
11-41 terns, 95-98
conducting groups C/B, 17-38 interaction pattern modification,
efficacy of, 11-13 99-101
frequency and duration, 17 reality testing in, 101-105
management problems, 38 stresses induced by treatment,
structural considerations, 13-17 105-106
Depression therapy (self-control group), Fault attributions. See Attributions
67-94 Feedback
application of, 69-71 alcoholics, 175-176
model of, 67-69 apprenticeship model, 306
therapy manual, 71-92 couples therapy, 118
340 INDEX
Feedback (Cont.) Homework (Cont.)

depression groups, 37 sexual enhancement groups, 223-224,
Rational-Emotive therapy, 60 237-247
self-control model, 68 Homogeneous groups, 12, 16
Flooding Homeyan models, 2
agoraphobia, 202-204, 206-207, 216 Humor, 232
sexual enhancement groups, 230 Hysterical response style, 200-201
Focusing, agoraphobia treatment,
207-208, 209 Identification, 20
Frequency Immediate consequences, 79-83
group meetings, 17 Impulsive behavior
sexual enhancement groups, 228 alcoholics, 176
travel groups, 204-205 couples therapy, 117-118
Friendship, 287-289 Individual sessions
Frigidity, 229 competitive feelings and, 139
conjoint session compared, 137
Goal Attainment Scale, 167, 169, 173, couples therapy and, 127, 139-142,
175, 177
151-152
Goal setting, 86-88 purpose of, 131
Go-around format, 20 sexual enhancement, 222
sexual enhancement groups, 226, 236 Institute for Rational Living (N.Y.C.), 44
Grounding, 208-209 Intelligence, 158-159
Ground rules, 20-21 International Training Standards and
Group composition, 16-17
Review Committee, 60
Group setting, 59 Intimacy, 262, 263, 270, 271
Group size Involvement, 187-189
Rational-Emotive therapy, 59 Irrational beliefs. See Reality distortion
sexual enhancement groups, 225 Isolation, 262
Group supervision model, 323-335
advantages for patient in, 330 Kelly Rep Test, 174
advantages for supervising therapist,
229-230
Labeling, 6, 229
advantages for trainee, 326-329
Language, 230-231, 235
format in, 323-326
Leader qualifications, 60
preception and apprenticeship
Leaders, sexual enhancement groups,
modalities in, 331
228-230
techniques in, 332-334
Learning theory, 7
Hedonism, 232 Legal codes, 7
Heterogeneous groups, 12, 16 Lesbianism, 226
Homework Living alone groups, 261-301
agoraphobia groups, 205 advantages of single life-style,
alcoholic groups, 173 296-298
cognitive therapy, 8-9 aloneness and loneliness, 268-270
couples therapy, 111 being at horne, 279-282
depression groups, 35-37 daily domestic living, 275-279
living alone groups, 266-268, 269-270, going out alone, 282-285
273-275, 279, 285, 290-291, 296 introduction and rationale, 264-268
Rational-Emotive groups, 51 others and, 285-291
self-control groups, 74-75, 77, 79, 80, physical relationship with self,
83, 84-86, 87, 88-89, 90, 91 292-296
INDEX 341
Living alone groups (Cont.) Paradoxical intention, 210

sex and approval needs, 270-275 Passivity, 158
termination in, 298-299 Perceived reality, 194
Loneliness, defined, 269 Performance anxiety, 148
Lonesomeness, defined, 269 Personalization, 6-7
Love addiction, 141 Pleasant Events Schedule, 143
Pleasure, 44
Magnification, 5 Pleasure Predicting Form, 142
Maladaptive formulas, 149-153 Positive distortion, 7
Maladaptive thought processes, 160-161 Positive self-statements. See Self-
Marriage contracts concept, 110 statements
Marriage counseling. See Couples Preception, 318-320
therapy Preorgasmic groups, 226
Masturbation Preparatory interviews, 17
education, 236 Problem-oriented groups, 14-15
homework, 238-244 Process-oriented groups, 14-15
living alone groups, 294-296 Pseudoagoraphobia, 199n1
orgasm, 222 Psychodrama, 50
therapy, 223-224 Psychological reactance, 97
Media usage, 60 Psychosis
Mind reading, 5 Rational-Emotive therapy, 53-54, 62
couples therapy, 142 young adult chronic patients, 189
family system, 98 Psychotherapy, 1
Minimization, 5
Minnesota Multiphasic Personality In- Rape, 235
ventory (MMPI), 68, 201 Rational behavior therapy, 1
Mislabeling, 6 Rational-Emotive therapy (RET), 1,
Modeling 43-65
sexual enhancement groups, 230 application of, 59-60
young adult chronic patients, 191, 194 basic concepts in, 44-45
Molestation, 235 couples therapy, 108-109
Mood evaluation, 54-56
cognitions and, 72 goals of, 43-44
self-statements and, 77-79 limits of, 53-54, 62-64
Morality. See Values management in, 58
Motivation, 54 mechanisms in, 47-53
Multimodal therapy, 1 research, 60-62
Multiple therapists, 186 strengths and limitations of, 62-64
See also Co-therapy theory of, 45-46
therapy proces~ in, 46-47
Negative prediction, 5 treatment, 56-57
Reality distortion
Open groups, 16 ABC model, 48
Orgasm ali-or-nothing thinking, 4
couples therapy, 148 arbitrary inference, 5
learned response, 236 cognitive and behavioral strategies, 8
masturbation, 222 couples therapy, 108, 109
women, 221 disqualifying the positive, 4-5
Overgeneralization, 4 emotional reasoning, 5-6
Overt self-reinforcement, 88-90 irrational belief systems and, 7
342 INDEX
Reality distortion (Cont.) Self-control groups

labeling and mislabeling, 6 case example of, 92-93
magnification and minimization, 5 depression, 67-94
overgeneralization, 4 Self-Control Questionnaire, 69
personalization, 6-7 Self-evaluation, 68, 69
positive distortion, 7 Self-fulfilling prophecy, 144
Rational-Emotive therapy, 44, 45, 55 Self-image, 175
reality distortion and, 7 Self-instruction
selective negative focus, 4 agoraphobia treatment, 210
should statements, 6 couples therapy, 117-119
treatment, 7-8 Self-massage, 292-293
types of, 3-7 Self-monitoring
young adult chronic patients, 194 depression groups, 36
Reality testing self-control groups, 69, 71-76
alcoholic groups, 171-172 Self-presentation, 169-170, 171
family system therapy, 101-105 Self-regulation, 67
unrealistic expectations and, 111-112 Self-reinforcement, 68, 69, 88-91
Referrals, 54 Self-statements, 74-76, 77-79
Reformulation, 310 Sensory deprivation, 262
Rehearsal, 50-51 Severity of Agoraphobic Scale, 205
Reinforcement Sex education, 236
couples therapy, 109, 116, 120 Sex role
family system and, 96-97 agoraphobia, 205n3, 218
sexual enhancement, 224 couples therapy, 114
Relationship Enhancement program, 117 family system therapy, 103, 106
Religion sexual enhancement, 223, 231, 232
education, 7 Sexual dysfunction, 111, 147-149
Rational-Emotive therapy and, 62 Sexual enhancement groups (for wom-
sexual enhancement, 232 en), 221-260
Research, 60-62 case examples, 247-258
Research Diagnostic Criteria for Major composition of, 225-226
Affective Disorder, 69 format of, 228-230, 234-237
Resistance, 187, 189 goals of, 225
Reward-menu exercise, 90 homework for, 237-247
Role playing physiology of, 235-236
agoraphobia treatment, 207-208, 218 portrait of, 226-228
alcoholic groups, 170-171, 174 style for, 224-225
communication training, 309-310 themes in, 230-234
couples therapy, 140 Sexuality, living alone groups, 288-290
Rational-Emotive therapy, 50-51 Shame, 51-52
young adult chronic patients, 194 Should statements, 6
Romantic love, 262, 263 Simple agoraphobia, 200n2
Singleness. See Living alone groups
Schizophrenia, 183 Situations Rep Test, 167, 174
Selective abstraction, 192 Social learning, 7
Selective negative focus, 4 Sociopathy, 54
Self-acceptance Somatic feedback, 175-176
Rational-Emotive therapy, 43, 52-53 Specificity, 8
sexual enhancement, 232 Spielberger Trait Anxiety Inventory, 167
Self-concept, alcoholism, 158 Speilberger State Anxiety Scale, 170
INDEX 343
Stress innoculation training, 194 Travel groups (Cont.)

couples therapy, 118-119 flooding and, 202-204
Suicidal clients, 11 frequency and duration of, 204-205
Summarization, 37 structure and format of, 205-216
Trust, 53
Temple Medical School, 201 Two-way dialogue, 310-311
Terminal hypotheses, 114-115
Termination Understanding, 189-191
living alone groups, 298-299 Unrealistic expectations, 108-113
Rational-Emotive therapy, 57
Therapist-client relationship Values, 43-44, 62
apprenticeship model, 305, 311-314, Videotape, 60
315
family system therapy, 99 Wechsler Adult Intelligence Scale
group supervision model, 330 (WAIS), 158
living alone groups, 264 Wechsler-Bellevue Scales, 158
Rational-Emotive therapy, 46-47, 58 Women
young adult chronic patients, 187, self-control therapy, 68
190-191 sexual enhancement groups for,
Thought stopping, 210 221-260
Three-way dialogue, 310-311
Training. See Apprenticeship model; Young adult chronic patients, 183-198
Group supervision model patient populations, 183-185
Travel groups treatment stages, 185
components of, 204 therapy guidelines for, 185-195

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Cognitive Therapy with

Couples and Groups

Springer Science+ Business Media, LLC

©1983 Springer Science+Business Media New York

}ANIS LIEFF ABRAHMS, Department of Psychology, Yale University, New

AARON T. BECK, Department of Psychiatry, School of Medicine, Univer-

RICHARD C. BEDROSIAN, Massachusetts Center for Cognitive Therapy,

DAVID D. BuRNS, Department of Psychiatry, School of Medicine, Uni-

ANNA RosE CHILDRESS, Department of Psychiatry, School of Medicine,

MARK D. EvANS, Department of Psychology, University of Minnesota,

MEYER D. GLANTZ, National Institute on Drug Abuse, Division of Clini-

VINCENT B. GREENWOOD, Center for Cognitive-Behavioral Therapy, 5225

STEVEN D. HoLLON, Department of Psychology, University of Min-

SusAN }ASIN, California School of Professional Psychology, 3974 Sorren-

WILLIAM McCouRT, Southwood Hospital, Norfolk, Massachusetts

STIRLING MooREY, The Maudsley Hospital, Denmark Hill, London SES,

MICHAEL W. O'HARA, Department of Psychology, University of Iowa,

LAURA PRIMAKOFF, Center for Cognitive Therapy, Department of Psy-

LYNN P. REHM, Department of Psychology, University of Houston,

SusAN R. WALEN, Department of Psychology, Towson State University,

RICHARD L. WESSLER, Department of Psychology, Pace University,

It is with great pride and satisfaction that I welcome the publication of

For virtually every model of individual psychotherapy that has been

1. Cognitive Therapy: An Overview 1

2. Cognitive Therapy for Depression

STEVEN D. HoLLON AND MARK D. EvANS

3. Rational-Emotive Therapy in Groups 43

4. Self-Control Group Therapy of Depression 67

5. Cognitive Therapy in the Family System 95

6. Cognitive Therapy with Couples 107

7. Cognitive-Behavioral Strategies to Induce and Enhance

8. Cognitive Therapy in Groups

9. Cognitive Therapy with the Young Adult

10. Cognitive-Behavioral Treatment of Agoraphobia

11. Sexual Enhancement Groups for Women 221

13. The Apprenticeship Model: Training in

14. The Group Supervision Model in Cognitive

The historical roots of cognitive-behavior therapy are mixed. Kelley

in Adlerian and Horneyan models as central to their formation of a

DEFINITION OF COGNITIVE THERAPY

Cognitive therapy is a relatively short-term form of psychotherapy

THE MYTH OF SIMPLICITY

demonstrated by major practitioners or by their students (many of the

particular schema, it generates specific distortions or more general styles

1 This list and descriptions was developed by David Burns (1980).

to dysfunctional behavior, it should be noted that at some point each of

UNDERLYING ASSUMPTIONS AND IRRATIONAL BELIEFS

In terms of treatment, the first issue looked at would be the distor-

The cognitive therapist makes up problem lists and specifies the

COGNITIVE AND BEHAVIORAL STRATEGIES

A number of cognitive strategies are utilized to help patients test the

An important part of cognitive therapy is the idea that therapy does

so much as collaborating with the therapist. An important part of the

Arieti, S. Cognition in psychoanalysis. Journal of the American Academy of Psychoanalysis.

STEVEN D. HoLLON AND MARK D. EvANS

Can depressed patients be treated with cognitive therapy in a group

THE EFFICACY OF GROUP APPROACHES

Depressed and suicidal clients traditionally have been considered

STEVEN D. HoLLON AND MARK D. EvANS • Department of Psychology, University of

The available evidence favors a structured, time-limited, problem-

As in individual cognitive therapy, the fundamental goals of group

practical problems that may arise in a group context. In the following

Problem-Oriented versus Process-Oriented Groups